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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 most common cancer in dogs and 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 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

4 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

5 Clinical Signs

6 Clinical Signs

7 Clinical Signs

8 Clinical Signs

9 Clinical Signs

10 Clinical Signs

11 Clinical Signs

12 Holly Hoffman – Wichita Falls TX
Clinical Signs Fred Holt – Tioga TX Gregory Wood – Katy TX Holly Hoffman – Wichita Falls TX

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 circulating 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 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 Clinical Signs CBC Neutrophilia 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

24 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 Feline renal LSA

25 Clint Duncan – Spring TX John Wood – Lufkin TX
Kevin Acuna – Nacogdoches TX

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 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 Responded to chemo within a few days Remission 6 months End – recurrence of initial clinical signs

36 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

37 Clinical Signs Renal lymphoma in a cat

38 Clinical Signs Renal lymphoma in a cat

39 Clinical Signs gastric lymphoma in a cat with ascites

40 Clinical Signs Abdominal effusion and infiltrated omentum in a cat

41 Clinical Signs Hypoechoic liver - lymphoma

42 Clinical Signs Hyperechroic liver - lymphoma

43 Clinical Signs Stomach & duodenum in a dog with lymphoma

44 Doug Ashburn Lufkin TX Andre Michael Tyler TX Elizabeth Beck Luling TX

45 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

46 Clinical Signs

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

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

49 Clinical Signs

50 Clinical Signs Interstitial pulmonary nodules in a dog with lymphoma, enlarged lymph nodes

51 Clinical Signs Pleural effusion in a dog with lymphoma

52 Clinical Signs ECG VPCs if splenic mass
Possible arrhythmia if hypercalcemia Prolonged PR interval (>0.14sec) 1st degree AV block 2nd degree AV block P wave not followed by QRS Ventricular fibrillation if severe Calcium (>18)

53 Hypercalcemia of Malignancy
aka Pseudohyperparathyroidism aka HHM (humoral hypercalcemia of malignancy) HHM is most common cause of hypercalcemia in the dog and cat 67% of dogs with hyperCa have cancer 33% of cats with hyperCa have cancer Dogs with HHM most often have Anal sac adenocarcinoma LSA multiple myeloma Cats with HHM most often have LSA or SCC

54 Hypercalcemia of Malignancy
90% of dogs with anal sac tumors have HHM >50% are hypercalcemic at diagnosis 10-35% of dogs with LSA have HHM 15-20% of dogs with multiple myeloma have HHM Cats with LSA and HHM are most likely to have cranial mediastinal lymphoma >90% of dogs with LSA and HHM have enlarged lymph nodes

55 Hypercalcemia of Malignancy
Some tumors release PTH-rp Parathyroid hormone related protein Stimulates osteoclastic bone resorption Increases renal tubular reabsorption of calcium Made in low amounts by normal tissues Thought to regulate calcium transport during gestation and lactation Other humoral factors are involved in HHM Bony invasion can contribute to HHM

56 Hypercalcemia of Malignancy
Clinical Signs of HHM PU-PD Weakness, lethargy Anorexia, weight loss Vomiting, diarrhea

57 Hypercalcemia of Malignancy
Diagnosis Rule out lab artifact Fasting prevents lipemia No hemolysis Confirm hypercalcemia is real Ionized calcium Follow reference lab handling guidelines Altered by temperature, pH and CO2 Look for tumors Rectal exam, LN palpation, imaging, CBC Sample bone marrow if cytopenias Send PTH, PTHrp and iCa++ to Michigan

58 Hypercalcemia of Malignancy
Diagnosis If concurrent azotemia, it can be difficult to distinguish HHM from renal hypercalcemia Hypercalcemia can cause nephrotoxicity Marked azotemia and mild hypercalcemia is more consistent with renal disease Marked hypercalcemia with mild azotemia is consistent with HHM Phosphorus often high with renal disease Phosphorus often low with HHM iCa++ high with HHM iCa++ normal to low with renal failure

59 Hypercalcemia of Malignancy
Differential Diagnosis Hypercalcemia H = Hyperparathyroidism (1°, 3°, hyperplasia), HHM, houseplants, hyperthyroid (cats) A = Addison's disease, aluminum toxicity, vitamin A R = Renal disease, raisins/grapes (dogs) D = Vitamin D toxicosis (granulomatous dz), drugs, Dovonex, dehydration, diet I = Idiopathic (cats), infectious, inflammatory O = Osteolytic (osteomyelitis, immobilization, local osteolytic hypercalcemia, bone infarct) N = Neoplasia (HHM and LOH), nutritional S = Spurious, schistosomiasis, salts of calcium, supplements

60 Hypercalcemia of Malignancy
Differential Diagnosis Hypercalcemia Diagnostic Chart 16 conditions and 10 blood parameters Treatment Algorhythm Clinically ill with high iCa++ Chronic hypercalcemia without illness Idiopathic hypercalcemia in cats

61 Diagnosis Cytology Avoid sampling the submandibular lymph nodes, as they are most prone to inflammation Use “core technique” – needle only with no attached syringe for aspiration, then attach 10-12cc syringe full of air to squirt onto slide Vertical pull apart, as lymphoid cells are fragile Horizontal smears destroy the cells (“smudge cells”)

62 Diagnosis Cytology Normal lymph node Reactive lymph node
Mostly small lymphocytes Smooth chromatin, scant cytoplasm, no prominent nucleoli 1-1.5x size of RBC Fewer intermediate & large lymphocytes Occasional neutrophil, macrophage, plasma cell, mast cell But pyramid of maturation is conserved Reactive lymph node Can have many blasts Many cell types present

63 Diagnosis Cytology >80% lymphoblasts = large cell lymphoma
3-5x size of RBC More abundant cytoplasm, round to slightly cleaved nucleus, pale chromatin, prominent nucleoli Small cell lymphoma Other cells are largely missing Not many intermediate or large lymphocytes Difficult cytologic diagnosis (need histopath)

64 Diagnosis Cytology - cats Immunoblastic lymphoid hyperplasia
Aka atypical follicular lymphoid hyperplasia Peripheral LN hyperplasia in a young cat is more likely to be this than lymphoma Associated with FIV or FeLV positive Pyramid of maturation preserved Very large immunoblastic lymphoid cells are present Prognosis after treatment with corticosteroids is excellent in retroviral negative cats (beware of latent infection)

65 CR Schilling Lufkin TX Robert Conces Huntsville TX Conces Compadre Hunstville TX

66 Diagnosis Normal lymph node

67 Diagnosis Reactive lymph node

68 Diagnosis Feline large cell lymphoma

69 Diagnosis large cell lymphoma

70 Diagnosis SI biopsy touch prep Small cell lymphoma on histopath

71 Diagnosis SI biopsy touch prep Large cell granular lymphoma (feline)
Azurophilic granules

72 Diagnosis FNA enlarged kidney diffusely hyperechoic
Large cell lymphoma (feline)

73 Diagnosis Chylothorax – mediastinal mass Thymoma

74 Diagnosis Chylothorax – mediastinal mass
Mediastinal Lymphoma – large cell

75 Diagnosis Liver aspirate Hepatic Lymphoma

76 Diagnosis Liver aspirate Hepatic Lymphoma & fatty liver

77 Diagnosis Is histopathology necessary?
Lymph nodes cytology by boarded oncologist or pathologist is often sufficient Some circumstances might require biopsy Low grade lymphoma resembling mature lymphocytes Feline lymphomas Small cell lymphomas in dogs Severe inflammation and necrosis GI lymphoma (full thickness biopsies) Hepatic lymphoma

78 Diagnosis Cell Size – Degree of anaplasia
Most dogs have large cell lymphomas Most cats have large or intermediate cell lymphomas Small cell lymphomas are more common in the cat than in the dog Small cell more common in old cats Large cell more common in young cats

79 Diagnosis Special tests for atypical sites Nasal rads in cats
Open mouth, DV, frontal sinus skyline Soft tissue opacities Turbinate lysis Nasal biopsy in cats Anterograde and retroflexed behind soft palate blind biopsy yields diagnosis more often than rhinoscopy guided Use radiographs as a guide Rhinoscopy – low yield

80 Diagnosis Right nasal lymphoma in a cat

81 Diagnosis posterior nares – small mass on the left

82 Diagnosis posterior nares – small mass on the left

83 Diagnosis Nasal biopsy Platelet count and BMBT
Anesthetize and intubate the dog Count 4x4 gauze use to pack off the pharyngeal area Elevate the shoulders above the nares Absorbent pad on the floor

84 Mary Marble – Frankston TX Thomas Dunn – Orange TX
Celeste Hill – Sweetwater TX

85 Diagnosis Nasal biopsy Platelet count and BMBT
Anesthetize and intubate the dog Count 4x4 gauze use to pack off the pharyngeal area Elevate the shoulders above the nares Absorbent pad on the floor Wait 10 minutes prior to beginning anesthetic recovery Hospitalize overnight – they sneeze blood

86 LSA - Stage Stage I – Single node or site involved
No evidence of distant metastasis Stage II - Two or more lymph node regions both on the same side of the diaphragm Stage III - Two or more lymph node regions on different sides of the diaphragm Stage IV - Any lymph nodes PLUS liver or spleen involvement Stage V - Involvement of extranodal tissue

87 LSA - Stage Substage – added to any stage
Substage A – no clinical signs Substage B – illness caused by tumor Histopathologic grade – MI Little effect on prognosis Staging of limited prognostic value EXCEPT Stage V worse prognosis than others Substage B negatively impacts prognosis

88 Classification Location 80% of dogs with LSA have multicentric
Cat lymphomas not as likely to be multicentric as in dogs GI most common in cats mediastinal 2nd most common Cats with multicentric LSA are less likely to have peripheral lymphadenopathy than dogs Skin Lymphoma – different behavior than the typical multicentric lymphoma in dogs T cell in dogs – resistant to treatment Both T and B cell in cats – variable response to treatment

89 Classification Immunophenotyping – immunohistochemistry, flow cytometry, PCR B (CD79) or T (CD3) cell? Also null cell lymphomas Dog LSA – >70% B cell, <30% T cell Cat LSA – B cell more common than T cell More of a prognostic indicator in dogs as compared to cats High grade B lymphomas have better response and longer survival than high grade T cell lymphomas

90 Treatment - Chemotherapy
Many protocols, and most have similar prognosis and outcome CHOP – cyclophosphamide, doxorubicin, Oncovin (vincristine), prednisone COPA – cyclophosphamide, Oncovin, prednisone, Adriamycin (doxorubicin) VELCAP – vincristine, Elspar, cyclophosphamide, Adriamycin, prednisone Other induction protocols are out there, but those including these 4 drugs are thought to be most effective Elspar is added for high tumor burden

91 Treatment - Chemotherapy
Examples of CHOP Protocols Wisconsin 19 Week Protocol (4) Wisconsin 25 Week Protocol (4) Same as above with 6 weeks off TAMU Canine Large Cell Protocol (2) TAMU Feline Large Cell Protocol (7) Tufts VELCAP-L (6) Final “L” distinguishes from another shorter intermittent Tufts protocol Ohio State 3 Week Cycle (max)

92 Treatment - Chemotherapy
Ohio State 3 Week Cycle Week 1 - doxorubicin 30 mg/m2 IV 1 mg/kg in dogs under 15 kg Dispense prednisone 20 mg/m2 PO EOD Week 2, day 1 - vincristine 0.7 mg/m2 IV Week 2, day 3 - Cyclophosphamide 200 mg/m2 PO Week 3 – vincristine 0.7 mg/m2 IV Repeat for weeks (7-9 cycles), or until out of remission Doxorubicin reaches maximum lifetime dose

93 Treatment - Chemotherapy
Other protocols – with prednisone See Rescue Handout for details Doxorubicin q3 weeks Doxorubicin + cyclophosphamide Lomustine q3-4 weeks Oral Chemotherapy Chlorambucil 6-8 mg/m2 QOD Prednisone 40 mg/m2 PO SID, then QOD CBC every 2-3 weeks

94 Treatment - Chemotherapy
Most protocols last about 5-6 months (20-25 weeks) Older protocols continued chemo until the patient came out of remission “Maintenance Therapy” Current thinking is that chemo beyond 25 weeks is not beneficial when in remission Maintenance chemo may increase drug resistance at relapse If relapse occurs more than 2-3 months after chemo stopped, 60-70% will respond again to CHOP Maintenance chemo increases cost of chemo and increases side effects

95 Treatment - Chemotherapy
Maintenance therapy beyond 25 weeks indicated only for indolent low grade tumors Typical response to chemo for large cell lymphoma in dogs: In remission within 4-8 weeks 5-6 months chemo 2-3 months remission after chemo Variable response to rescue therapy Minimal illness Each successive remission lasts as about half as long as the last More than 3 remissions is unusual

96 Treatment - Chemotherapy
Common misconceptions My pet will lose his hair My pet will likely be ill as a trade off for attempting a longer life It would be better for my pet to die of cancer than to die of chemo treatment

97 Treatment - Chemotherapy
Things important to say You will likely think your dog is cured The probability of this is just about zero I can give you the averages, but whatever happens to you is 100% for you If at any time you want to stop chemo, all you have to do is say the word You know your pet best, and what is best for your pet. Our job is to give you information and help you manage your pet’s cancer as you think best. You are in the driver’s seat and we are here to help.

98 Treatment - Chemotherapy
Rescue Therapy Drugs used at the time of relapse are no longer effective and should not be used Repeat CHOP if not being used at relapse Then maximize doxorubicin dose Then try either CCNU and MOPP, in either order Then try various other rescue protocols

99 Treatment - Chemotherapy
Low Grade, small cell tumors GI lymphomas in cats CLL in dogs Chlorambucil 15 mg/m2 PO SID x 4d Repeat every 3 weeks Prednisone 40 mg/m2 PO SID 70-75% remission Median remission 19 months

100 Treatment - Chemotherapy
ALL Can try large cell protocol, but expect more myelosuppression Or Cytosine arabinoside 400 mg/m2 over 6-8 hours Administer weekly Monitor for sepsis and treat accordingly Blood transfusions as needed for RBC Platelet rich plasma for platelets Whole fresh blood for depleted factors

101 Other Treatments Intestinal resection and anastomosis for obstructive GI LSA Whole body radiation Nasal cavity radiation Monoclonal antibodies Cerebral lesions Mannitol, furosemide, diazepam acutely Chemo long term Anticonvulsants (zonisamide or phenobarbital) Natural alternatives

102 Other Treatments Treatment of Hypercalcemia Handout
Treat if >15-16 or symptoms IV 0.9% NaCl Increased GFR and calciuresis Decreases renal calcium reabsorption Furosemide 1-4 mg PO BID inhibits Ca++ reabsorption in ascending loop of Henle Prednisone 1-2 mg/kg PO BID Inhibits VitD and GI calcium absorption Cytotoxic effect on LSA and myeloma

103 Other Treatments Treatment of Hypercalcemia Handout
>18 is a medical emergency Salmon calcitonin 4-8 U/kg BID-TID Pamidronate 1-2 mg/kg IV in 0.9% NaCl over 2–4 hrs; repeat in 2-4 weeks) Zoledronate 0.25 mg/kg IV over 15 minutes q 4-5 weeks

104 AJ Clemmons Liberty Hill TX Thomas Hembree Wells TX Bethany Moore Austin TX

105 Prognosis Response to chemotherapy – canine large cell multicentric lymphomas 70-80% achieve full remission 20-25% are partial or non-responders Average length of remission is 10 months Median survival 12 months 20-25% survive 2 years or longer Each remission is shorter lived and more difficult to achieve Every tumor is expected to eventually become responsive to all treatment

106 Prognosis Response to chemotherapy – canine large cell multicentric lymphomas Short term prognosis usually good, long term prognosis is invariably dismal Staging doesn’t matter, except V is worse Grade doesn’t matter Things that worsen prognosis systemically ill (substage B) Hypercalcemia dyspnea on presentation Bone marrow involvement, especially if cytopenias T cell is worse than B cell

107 Prognosis GI lymphoma is more often T cell in dogs
Median survival 13 days for SI LSA Colorectal LSA can have prolonged survival There can be a histopathologic gray area between IBD and LSA Some Dx LSA behave as IBD Some Dx IBD behave as lymphoma Perhaps misdiagnosed? Lymphoid granulomatosis in dogs is highly variable 6 days to 4 years

108 Prognosis ALL has grave prognosis Days to weeks common
Occasionally a few months Chemo may not prolong life ALL distinguished from Stage V LSA (bone marrow) by immunohistochemistry The latter does not carry grave prognosis, though not as good as lower stages Death usually by hemorrhage

109 Prognosis Prognostic indicators in cats Retroviral status
Anatomic location Initial response to therapy Stage & grade do not matter immunophenotyping matters less in cats as compared to dogs Some of the indolent low grade tumors can have long survivals (2-3 years+) GI small Lymphoma in cats chronic lymphocytic leukemias in dogs

110 Prognosis Nasal lymphoma in cats increased risk for kidney lymphoma
Presence of anorexia worsens prognosis if not treated with chemo or radiation Median survival 135 days if anorectic Median survival 320 days if eating Same prognosis for chemo alone, radiation alone, or both together Median survival 536 days Much shorter MST if cribriform breach (76 days)

111 Prognosis Mediastinal lymphoma in cats
Associated more with FeLV+ than GI Younger cats than GI LSA Feline Hodgins-like lymphoma Not common Affect lymph nodes in head and neck Cells are of mixed phenotype Long term prognosis is good

112 Prognosis Hepatic lymphoma in cats Associated more with FeLV+ than GI
Younger cats than GI LSA Cutaneous Lymphoma Better prognosis in cats - B cell 50% remission in dogs – T cell Average remission 4-6 months in dogs CCNU + Elspar in dogs Treated as multicentric in cats CHOP for large cell Chlorambucil + pred for small cell

113 Client Handouts Lymphoma in Dogs Lymphoma in Cats Skin Lymphoma
Acute Lymphoid Leukemia Nutritional Alternatives for Cancer Drug Handouts discussed under chemotherapy (Sunday)

114 Acknowledgements Philip J. Bergman, DVM, MS, PhD, DACVIM (Oncology) VIN, BrightHeart Veterinary Centers Louis-Philippe de Lorimier, DVM, ACVIM (Oncology) VIN, U Illinois Urbana-Champaign Karri A. Meleo, DVM, ACVIM (Oncology), ACVR VIN, Veterinary Oncology Services, Edmonds, WA

115 Acknowledgements Mark Rishniw, BVSc, MS, ACVIM (SAIM), ACVIM (Cardiology) VIN, Clinical Research Coordinator Ithaca, NY Kurt R. Verkest, BVSc, BVBiol, MACVSc (Small Animal) VIN, Univ Queensland, Australia Kari Rothrock, DVM, Tennessee

116 Acknowledgements Linda Shell, DVM, DACVIM (Neurology) VIN Consultant
Nancy Johnstone McLean, DVM, DACVO U of Tennessee CVM Amanda Podles, DVM Massachussets

117 Acknowledgements Robert J. Vasilopulos DVM, DACVIM (Internal Medicine)
VIN Consultant, Vet Spec Ctr of Tucson Dennis J. Chew, DVM, ACVIM (Internal Medicine) The OSU CVM, Columbus, OH Patricia A. Schenck, DVM, PhD Mich State U, East Lansing, MI, USA

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