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Managing Lymphoma in Small Animal Practice

Managing Lymphoma in Small Animal Practice. Wendy Blount, DVM. Lymphoma. aka lymphosarcoma (LSA) Other than euthanasia in shelters, cancer is the #1 killer of dogs LSA most common cancer in dogs & cats Most common cause of hypercalcemia in dogs and cats 30% of cats with cancer have lymphoma

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Managing Lymphoma in Small Animal Practice

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  1. Managing Lymphoma in Small Animal Practice Wendy Blount, DVM

  2. Lymphoma • aka lymphosarcoma (LSA) • Other than euthanasia in shelters, cancer is the #1 killer of dogs • LSA most common cancer in dogs & cats • Most common cause of hypercalcemia in dogs and cats • 30% of cats with cancer have lymphoma • 24% of dogs with cancer have lymphoma • Most common spinal cord tumor in the cat • Most common brain tumor in the cat • Most common nasal tumor in the cat • Most common liver tumor in the cat

  3. Lymphoma Juan Carlos Garza – Houston TX x

  4. Etiology • GI lymphoma can be preceded by IBD in cats • Helicobacter spp increase risk of GI adenocarcinoma in people, and are often present in gastric LSA histopath in cats • FeLV predisposes to LSA in cats • Lymphoma respects age less than other tumors

  5. Clinical Signs Vary tremendously by tumor location Multicentric lymphoma most common • Multiple painless enlarged lymph nodes, hepatomegaly, splenomegaly in dogs • Enlarged mesenteric lymph node, hepatomegaly, splenomegaly in cats • Fever • Other locations Ocular lymphoma • Third eyelid or conjunctival mass in cats • rapidly enlarges • Anterior or posterior uveal infiltrates and/or uveitis

  6. Clinical Signs

  7. Clinical Signs

  8. Clinical Signs

  9. Clinical Signs

  10. Clinical Signs

  11. Clinical Signs

  12. Clinical Signs

  13. Clinical Signs Vary tremendously by tumor location • GI lymphoma (focal or diffuse) • Vomiting, diarrhea, steatorrhea, melena • Hematochezia, mucoid feces, tenesmus • Mass on rectal palpation • Anorexia, weight loss, lethargy • Abdominal pain or effusion • Palpable abdominal mass, thickened loops of bowel • Pallor, anemia if GI bleeding • Icterus if obstruction of bile duct

  14. Clinical Signs Nasal lymphoma • Unilateral or bilateral nasal discharge • Epistaxis, Sneezing • Dyspnea, stertor, nasal stridor • Facial distortion and ocular discharge • Intermediate to large cells

  15. Clinical Signs Nasal lymphoma • Unilateral or bilateral nasal discharge • Epistaxis, Sneezing • Dyspnea, stertor, nasal stridor • Facial distortion and ocular discharge • Intermediate to large cells

  16. Clinical Signs Nasal lymphoma • Unilateral or bilateral nasal discharge • Epistaxis, Sneezing • Dyspnea, stertor, nasal stridor • Facial distortion and ocular discharge • Intermediate to large cells • Neurologic signs if invasion of the cribriform plate – anterior forebrain • Seizures • Behavioral changes, obtunded, head pressing • Blindness, circling • CP deficits worst in rear

  17. Clinical Signs Spinal cord lymphoma • Extramedullary tumor • Onset chronic or acute • More common in cats than dogs • Localized severe spinal pain • Extramedullary tumors seem to be more painful than medullary • More pain receptors in these areas • LMN signs (flaccid weakness) 2 vertebrae caudal to the area of spinal pain • UMN signs (spastic paresis) caudal to that • Usually part of multifocal disease • Younger cats, up to 2 years of age • Difficult to diagnose, CSF often not diagnostic

  18. Clinical Signs Brain lymphoma • Symptoms caused by • Displacement of brain tissue • Disruption of blood brain barrier • Disruption of CSF and blood flow • Seizures the most common symptom in dogs (cerebral) • Lethargy, weight loss, obtunded • Circling, behavior changes, head pressing • Contralateral CP deficits worse in rear • Head tilt and ataxia in cats (caudal brain stem) • Brain herniation in the late stages • Coma, dilated pupils, death

  19. Clinical Signs Acute Lymphoblastic Leukemia (ALL) • Usually non-specific signs • May have coagulopathy of thrombocytopenia • Petechiae • Epistaxis, bleeding from the gums • Primary hemostasis disorder • Often part of multicentric disease • Usually “atypical cells” in circulation, but not always • “Aleukemic leukemia” • Cytopenias prompt bone marrow sample

  20. Clinical Signs Lymphomatoid granulomatosis • aka eosinophilic pulmonary granulomatosis • aka lymphoid granulomatosis • aka lymphoproliferative angitis • aka granulomatosis • Destructive angitis in the lungs • Atypical T-cell lymphoma • History of treated heartworm disease • May progress to lymphoma • Symptoms of pneumonitis

  21. Clinical Signs Renal lymphoma (feline) • Bilateral large, bumpy kidneys • The many signs of renal failure Mediastinal lymphoma (feline) • Dyspnea, coughing • Regurgitation • Horner’s Syndrome Hepatic lymphoma • Marked hepatomegaly, liver failure • Large cell in dogs, small cell in cats

  22. Clinical Signs Cutaneous lymphoma • Usually diffuse in the dog • Intense pruritis, resistant to treatment • Sometimes follows atopy • Two forms in cats • Epitheliotropic – diffuse • “Mycosis fungoides” • Intradermal nests of 5-10 cells • Usually large but sometimes small T cells • Non-epitheliotropic • Large B cells deeper in the dermis

  23. x x

  24. Clinical Signs CBC • Neutrophilia if gross disease • Lymphocytosis • atypical lymphocytes if ALL • May not have atypia with CLL • Anemia • Anemia of chronic inflammatory disease • Mild nonregenerative anemia • Iron deficiency anemia if GI bleeding • Regenerative or non-regenerative • Pancytopenia if leukemia is present

  25. Clinical Signs Panel • Hypercalcemia • Elevated ALT, SAP, GGT if hepatic LSA • Icterus – GI, hepatic, pancreatic LSA • Low albumin • PLE due to intestinal LSA • GI bleeding due to GI LSA • High globulins – B cell lymphoma • Low globulins – GI bleeding due to GI LSA • High BUN • Pre-renal - dehydration • Pre-renal - GI bleeding due to GI LSA • Feline - renal LSA

  26. Clinical Signs Panel - icterus with normal liver enzymes • A unique presentation in the cat • Differential diagnosis: • Pancreatitis – elevated fPLI • Lymphoma – cytology or histopathology • FIP – histopathology or diagnostic trifecta • Lymphopenia <1500/ul • Titer 1:160 or greater • Globulins >5.1 g/dl • Positive predictive value 89% • Negative predictive value 99% • Histopath and fluid analysis supportive • Fluid analysis chart

  27. Clinical Signs Abdominal Imaging (rads) • Abdominal mass – gut or lymph node • Hepatomegaly, splenomegaly • Gut obstruction • Abdominal effusion • Chyle or modified transudate • Thickened gut wall (muscularis) • Pneumoperitoneum if GI perforation • Mucosal craters • Soft tissue calcification if hypercalcemia • Bilateral renomegaly in cats

  28. Clinical Signs Bilateral renomegaly in cats

  29. Clinical Signs Cat with mid-abdominal mass and ascites

  30. Clinical Signs Hepatosplenomegaly due to multicentric lymphoma in a dog

  31. Clinical Signs Abdominal Imaging (US) • Enlarged mediastinal lymph node • Hepatomegaly • Hypoechoic focal to multifocal lesions • Generalized hypo- or hyper-echogenicity • Normal to nodular hepatic sonogram • Splenomegaly • Nodular to diffuse • hyper or hypoechoic

  32. Clinical Signs Lila • 1.5 year old female Rottweiler • Acute onset of abdominal pain and tachypnea • Has not eaten for 2 days, no vomiting, mucus in the stool • Abdominal splinting on palpation • Fever – 103.8F • CBC, panel – NSAF • cPLI – abnormal (>400) • Fecal float negative • No response to treatment with IV fluids and antibiotics for 2 days (began vomiting)

  33. Clinical Signs

  34. Clinical Signs Ileus and abdominal effusion

  35. Clinical Signs Lila • Abd US declined due to financial limitations • Elected diagnostic surgery • Generalized peritonitis, serosanguinous abdominal fluid • No obstruction or foreign body • Fluid analysis • Modified transudate • Neoplastic very large lymphoid cells • Cytology says “suspicious of lymphoma” • Histopathology of mesenteric lymph node confirms large cell lymphoma

  36. Clinical Signs Lila • Responded to chemo within a few days • Remission 6 months • End – recurrence of initial clinical signs Owner failed to “pay as she went” as promised, and never paid her balance of >$1,500

  37. Clinical Signs Abdominal Imaging (US) • Abdominal effusion • Soft tissue calcification if hypercalcemia • GI lesions • Gut obstruction – dilated fluid filled bowel • Thickened gut wall (muscularis) • Obliteration of gut layers • Pneumoperitoneum if GI perforation • Mucosal craters • Decreased motility

  38. Clinical Signs Renal lymphoma in a cat

  39. Clinical Signs Renal lymphoma in a cat

  40. Clinical Signs gastric lymphoma in a cat with ascites

  41. Clinical Signs Abdominal effusion and infiltrated omentum in a cat

  42. Clinical Signs Hypoechoic liver - lymphoma

  43. Clinical Signs Hyperechroic liver - lymphoma

  44. Clinical Signs Stomach & duodenum in a dog with lymphoma

  45. x x x x

  46. Clinical Signs Thoracic Imaging (rads) • Enlarged perihilar lymph nodes • Interstitial nodular pattern • Enlarged sternal lymph node • Mediastinal mass • Pleural effusion • Soft tissue calcification if hypercalcemia • Lymphoid granulomatosis • Soft tissue masses in the lungs • Interstitial to alveolar pattern • Enlarged lymph nodes • Pleural effusion

  47. Clinical Signs

  48. Clinical Signs Enlarged mediastinal lymph nodes and chylothorax in a cat with LSA

  49. Clinical Signs Enlarged mediastinal, sternal and perihilar lymph nodes in a dog with LSA

  50. Clinical Signs

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