Any tumour with distant metastasis, blood or BM involvement

Question 1

Lymphoma

Answer 1

Malignant proliferation of peripheral lymphoid tissues (eg lymph nodes) but can sometimes infiltrate bone marrow (stage V)
Complex disease /group of diseases – over 40 different subtypes based on – histology, anatomical location immunophenotype!

Question 2

Lymphoma – clinical signs

Answer 2

Asymptomatic / clinically well – but palpable mass/lymph node
Non-specific (general malaise, lethargy, inappetance, fever, weight loss)
Paraneoplastic disease
Hypercalcaemia (dogs>cats) – more T cell related, especially mediastinal mass
Hyperviscosity (rare) – more B cell (Ig) related
Organ specific signs - related to Anatomical classification

Question 3

What is the most common type of lymphoma in dogs

Answer 3

Multicentric

Question 4

What is multicentric lymphoma

Answer 4

Lymphadenomegaly – non-painful very enlarged LNs, usually generalised

Question 5

What is the most common type of lymphoma in cats

Answer 5

Alimentary / gastro-intestinal

Question 6

Outline alimentary/GI lymphoma

Answer 6

Usually in small intestine (focal or diffuse, ± LN enlargement), possibly stomach, colon rare
Vomiting, diarrhoea, weight loss, anorexia
Palpable abdominal mass, thickened loops intestine

Question 7

Difference in pathology grade of alimentary lymphoma

Answer 7

High grade (poor px) – large/intermediate cells, often B cell, usually palpable abdominal mass - focal, ± LN enlargement, but can be diffuse too
Low grade (good px) - small cell - mature lymphocytes, often T cell
thickened intestine – more diffuse but can appear grossly normal (Ddx is IBD)

Question 8

What do you expect to see of an ultrasonography of GI lymphoma

Answer 8

Mass, lymphadenomegaly
Thickening of gut wall
Loss of layering
Regional/segmental hypomotility – no peristalsis

Question 9

Outline Mediastinal (thymic) lymphoma

Answer 9

Common in younger cats (FeLV positive) – poor px
Better prognosis in FeLV negative cats
Common in dogs (often hypercalcaemic)
Often T cell (thymus derived)

Question 10

Clinical signs of Mediastinal (thymic) cancers

Answer 10

Cough, dyspnoea
Pleural effusion
Dull heart /lung sounds

Question 11

Difference between primary and secondary skin lymphoma

Answer 11

Primary skin lymphoma starts in skin as the primary site while Secondary skin lymphoma spreads to the skin from another site eg lymph nodes and is part of multicentric disease

Question 12

Primary skin lymphoma is always B cell derived (T/F)

Answer 12

False! Always T cell derived

Question 13

What is extranodal lymphoma

Answer 13

More common in cats than dogs
Sites other than LNs eg eyes, nose, brain, spine, kidney
Prognosis varies (nasal good, CNS poor)

Question 14

Outline the diagnosis of Lymphoma

Answer 14

Sample a representative lesion (mass) or LN
Examine representative fluid (eg pleural)
FNA for cytology is diagnostic in many cases
Biopsy is needed if any doubt from FNA or for more precise subclassifications /grade of lymphoma- Remove whole node to examine LN architecture

Question 15

What do you expect to see from a FNA of a patient with lymphoma

Answer 15

Large/intermediate size immature lymphoblasts

Question 16

Is High grade/large cell lymphoma common in both dogs and cats?

Answer 16

Most common canine multicentric presentation
Most common feline GI presentation

Question 17

Summarise high grade lymphoma

Answer 17

Immature, undifferentiated lymphoblasts, rapidly dividing
Needs aggressive chemotherapy

Question 18

What diagnostic test can i run from fluid gathered from FNA to test for lymphoma

Answer 18

Slides- Cytology
Fluid medium- Flow cytometry
DNA/PARR

Question 19

What is PARR

Answer 19

PARR (Polymerase Chain Reaction for Antigen Receptor Rearrangement) is a molecular diagnostic technique to detect clonal rearrangements in the genes encoding the antigen receptor in lymphocytes. This method helps diagnose and characterize lymphoid malignancies, such as lymphoma and leukemia, in animals. By amplifying specific regions of immunoglobulin or T-cell receptor genes, PARR identifies clonal expansions indicative of malignancy, providing valuable diagnostic information when conventional methods may be inconclusive.

Question 20

Summarise how flow cytometry is used to diagnose lymphoma

Answer 20

Sample Collection: A sample of cells, usually obtained from peripheral blood, bone marrow, lymph nodes, or other tissues suspected to be involved, is collected from the patient.

Cell Staining: The cells in the sample are stained with fluorescently labeled antibodies that specifically bind to cell surface markers characteristic of lymphocytes and their subpopulations.

Flow Cytometric Analysis: The stained cells are passed through a flow cytometer, a specialized instrument that can analyze the cells based on their fluorescence and light-scattering properties as they pass through a laser beam.

Cell Characterization: By measuring the intensity of fluorescence emitted by the labeled antibodies and analyzing light scatter properties, flow cytometry can identify and characterize different types of lymphocytes and detect abnormalities in their distribution and expression of cell surface markers.

Diagnosis of Lymphoma: In cases of lymphoma, flow cytometry can detect abnormal populations of lymphoid cells with atypical immunophenotypes, such as aberrant expression or loss of specific surface markers, altered cell size, or abnormal DNA content. These findings can help differentiate between different types of lymphoma (e.g., B-cell vs. T-cell lymphoma) and subclassify them based on their immunophenotypic profiles.

Question 21

Summarise PCR for Ag rearrangement

Answer 21

Purpose: PCR for antigen receptor rearrangement is used to identify clonal expansions of lymphocytes, indicative of lymphoid malignancies like lymphoma and leukemia.
Principle: The technique amplifies specific regions of antigen receptor genes using PCR, targeting conserved sequences within variable regions that undergo rearrangement during lymphocyte development.
Procedure: DNA is extracted from lymphoid tissue or cells, and PCR is performed using primers specific to the variable regions of immunoglobulin or T-cell receptor genes. This amplifies rearranged gene segments, allowing detection of clonal lymphocyte populations.
Detection: Amplified PCR products are analyzed using gel electrophoresis or other methods to visualize DNA bands. A monoclonal band indicates clonal expansion, suggestive of lymphoid malignancy.

Question 22

Outline staging of lymphoma

Answer 22

Bloods- Haematology reflects bone marrow cells as baseline prior to chemo and may see circulating LSA cells in blood
Biochemistry indicates organ involvement & PNSyndromes
FeLV and FIV status for cats

Diagnostic imaging of chest and abdomen and other sites

Urinalysis – baseline data

Bone marrow – stage V

Question 23

Summarise treatment of lymphoma

Answer 23

1st – Stabilise paraneoplastic syndromes if present
2nd - Treat the lymphoma ( Steriods-Pallative/Chemotherapy)

Question 24

What is the most common paraneoplastic syndrome of lymphoma

Answer 24

Hypercalcaemia

Question 25

Treatment of hypercalcaemia

Answer 25

Need to reduce the level of ionised Ca in blood by Correcting fluid deficit Restore circulating volume and support kidneys 0.9% saline diuresis at 2-3 x maintenance Loop diuretics (frusemide) optional once rehydrated

Question 26

Refractory hypercalcaemia

Answer 26

Condition where blood calcium levels remain persistently elevated despite treatment attempts

Question 27

Drugs used to treat refractory hypercalcaemia

Answer 27

Glucocorticoids (IV or oral) Decrease bone & intestinal absorption, promote renal excretion Toxic to lymphocytes (do not give prior to diagnosis of LSA) Calcitonin (SC) Decreases serum calcium Bisphosphonates (IV Pamidronate, Zoledronate or possibly oral alendronate) Decrease osteoclast activity Some antitumour activity (bone tumours) Potentially analgesic Renal toxicity possible with pamidronate (give lots of fluids)

Question 28

Indications of a good prognosis for lymphoma

Answer 28

Well patients (substage a) Low clinical stage (I or II) Low histological grade B cell immunophenotype (dogs - not yet shown in cats) Nasal site (cats and probably dogs) Complete remission (CR) to treatment (cats) Using Doxorubicin in protocol (cats)

Question 29

Indications of a bad prognosis for lymphoma

Answer 29

Sick patients (substage b) High clinical stage (V) – bone marrow T cell immunophenotype (dogs, not done in cats) Certain anatomical locations eg skin, CNS, ocular FeLV /FIV positive (cats) Low body weight at presentation (cats) – often GI Not achieving complete remission (cats) Prior steroid use (multidrug resistance)

Question 30

What is leukaemia

Answer 30

Haemopoietic malignancy that usually ORIGINATES in bone marrow – transformation of bone marrow cells and cell proliferation Usually results in increased numbers of specific circulating blood cells Can spread to peripheral lymphoid/haemopoietic organs

Question 31

How is leukaemia classified

Answer 31

LYMPHOID (most common) or MYELOID ACUTE or CHRONIC (myeloproliferative neoplasms)

Question 32

Summarise difference between lymphoid and myeloid leukaemia

Answer 32

Origin: Lymphoid Leukemia: Lymphoid leukemia originates from abnormal lymphoid stem cells, leading to the overproduction of immature lymphocytes (white blood cells) in the bone marrow and blood. Myeloid Leukemia: Myeloid leukemia originates from abnormal myeloid stem cells, resulting in the overproduction of immature myeloid cells, including red blood cells, white blood cells, and platelets. Cell Types Affected: Lymphoid Leukemia: Lymphoid leukemia primarily affects lymphoid cells, including B-cells, T-cells, and natural killer (NK) cells. Myeloid Leukemia: Myeloid leukemia affects myeloid cells, which give rise to red blood cells, white blood cells (other than lymphocytes), and platelets.

Question 33

Summarise difference between acute and chronic leukemia

Answer 33

Acute: Neoplastic transformation early in the cell lineage (proliferation of blasts) Chronic (myeloproliferative neoplasm (MPN)) :Neoplastic transformation late in the cell lineage (proliferation of mature differentiated cells)

Question 34

Summarise pathogenesis of leukaemia

Answer 34

Leukemia arises from genetic mutations in blood-forming stem cells, leading to uncontrolled proliferation and impaired differentiation of immature cells called blasts. These abnormal cells infiltrate the bone marrow, disrupt normal blood cell production, and may spread to other organs. Genetic mutations often confer resistance to apoptosis, allowing leukemic cells to survive and proliferate.

Question 35

Differentiate appearance of a patient with chronic and acute leukaemia

Answer 35

Chronic: Generally well Acute: Often sick

Question 36

Differentiate results of a clinical exam of a patient with chronic and acute leukaemia

Answer 36

Chronic: Clinically normal/ Mild lymphadenomegaly/ Big spleen/liver Acute: Big spleen/liver/ Mild lymphadenomegaly/ Pale mucous mbs

Question 37

Differentiate results of Haematology of a patient with chronic and acute leukaemia

Answer 37

Chronic: High white cell counts/ Mild cytopenias of other lines Acute: High /low WBC/ Immature circulating cells/ Cytopenias common

Question 38

Differentiate results of Biochemistry of a patient with chronic and acute leukaemia

Answer 38

Chronic: PNS may be present Acute: PNS less likely

Question 39

Differentiate results of Bone marrow of a patient with chronic and acute leukaemia

Answer 39

Chronic: Increased nos of well diff cells Possibly other lines decreased Acute: Increased nos of blasts Other lines decreased

Question 40

Leukaemia-Diagnosis

Answer 40

Haematology is suggestive –large numbers of malignant / aberrant cells on blood smear, cytopenias, etc Bone marrow sample is usually diagnostic – altered cell maturation, malignant cells etc Flow cytometry (blood or marrow) helps to differentiate cell lineage and precursors using specific abs to cell surface proteins

Question 41

Acute lymphoid leukemia vs Lymphoma

Answer 41

Both characterised by proliferation of large blast cells Lymphoma Malignant neoplasms of peripheral lymphoid tissues Can affect bone marrow (stage V) Prognosis is reasonable with chemotherapy Acute lymphoid leukaemia Originates within bone marrow Can spread to peripheral tissues Prognosis is poor even with chemotherapy

Question 42

How to differentiate between acute lymphoid leukaemia and lymphoma

Answer 42

Lymphoma Often well Massive lymphadenopathy < 30% blasts in the bone marrow CD34 –ve on flow cytometry Acute leukaemia Usually sick Mild lymphadenopathy Splenomegaly Usually severe haematological abnormalities > 30-40% blasts in bone marrow CD34 +ve on flow cytometry

Question 43

Multiple myeloma

Answer 43

Multiple myeloma is a type of cancer that affects plasma cells, a type of white blood cell that produces antibodies. Origin: Multiple myeloma originates in the bone marrow, where abnormal plasma cells proliferate uncontrollably. Pathogenesis: The exact cause of multiple myeloma is not fully understood, but it is believed to involve genetic mutations in plasma cells that lead to their uncontrolled growth and survival. Clinical Features: Multiple myeloma can cause various symptoms, including bone pain (due to bone destruction), weakness, fatigue, recurrent infections, anemia, kidney damage, and increased susceptibility to fractures.

Question 44

Diagnosis of multiple myeloma

Answer 44

Plasma cells in BM sample (>10%) Osteolytic bone lesions on radiographs Myeloma proteins in blood Myeloma proteins in urine

Question 45

how does multiple myeloma cause hypervisocity

Answer 45

Increased Production of Abnormal Proteins: In multiple myeloma, cancerous plasma cells produce abnormal monoclonal immunoglobulins, also known as M proteins or monoclonal gammopathies. These abnormal proteins can accumulate in the blood, leading to increased serum viscosity. Elevated Serum Protein Levels: As the concentration of abnormal proteins increases in the blood, the overall serum protein levels rise. This increase in protein concentration contributes to elevated blood viscosity.

Question 46

Signs of hyperviscosity

Answer 46

Heart: cardiomyopathy Ocular: retinal lesions/detachment Neurological: lethargy, seizures Kidney: azotemia Coagulopathy Lethargy, seizures, blindness, bleeding