Flashcards in Haematopoetic Neoplasia 2 (Annaleise Stell) Deck (51):
1
Most effective general type of tx for lymphoma
- systemic dz so systemic tx (ie. chemo)
- surgical indications rare (eg. solitary site lymphoma, good for Hodgkins like lymphoma in cats, acute intestinal obstruction)
- radiation for nasal lymphoma cats (survival 1.5-3y if responsive) and some localised lymphomas. Can also be used as RESCUE.
2
What non-chemo type drug is indicated in lymphoma cases?
> Prednisolone and dexamethasone
- cause lymphocyte apoptosis
- often in combo chemo protocols
- can be used ALONE for palliation but effect SHORT LIVED 2-3months
- do NOT give before making a dx, steroids promote multidrug resistance so "pre-tx" will reduce success rate in future
- if going to use in combination, do so from the start
3
Is chemo curative for lymphoma?
No remission not cure, will relapse
4
What protocol are available for tx lymphoma?
> COP
- cyclophosphamide , vincristine, prednisolone
- induction phase + ongoing oral maintainance (chlorambucil, methotrexate, prednisolone)
> CHOP
- doxorubicin containing
- more intensive initially, longer induction
- no maintainance
> COAP
- COP + cytosine arabinoside first week (good for CNS involvement)
- if remission @ 8weeks, maintainance is LP/LMP (chlorambucil [Leukeran,] prednisolone, +- methotrexate)
> LOPP (for high/intermediate T cell in dogs)
- vincristine, procarbazine, lomustine, prednisolone
- LMP maintainance if remission @ 6 months
5
What adverse effects may lomustine have?
hepatotoxic so monitor SAMe
6
Which cat lymphomas is cytosine arabinoside useful for?
- renal
- CNS (cytarabine crosses BBB)
7
Standard maintainance for cats
- chlorambucil and prednisolone EOD
8
How is low grade feline GI lymphoma tx?
> oral only, few side effects
- Chlorambucil [Leukeran]
- Prednisolone
(- can use cyclophosphamide or lomustine if relapse)
9
Outline a low budget protocol for tx lymphoma
- Prednisolone alone
- Prednisolone + chlorambucil (monitor haem)
- Lomustine +- prednisolone (monitor carefully for myelosuppression, hepatotox)
10
How can lymphoma relapses be tx?
- if not currently on tx, restart original protocol (re-induction)
- if receiving maintainence, restart induction protocol (re-induction)
- if relapsing during induction, use new drugs tumour not exposed to previously, preferably in combination (rescue) eg. DMAC (dex, melphalan, actinomycin D, cytarabine) or lomustine and L-asparaginase
11
Are resuce tx often successful?
Less successful than 1* induction
12
How can hypercalcaEMIA BE MANAGED?
- tx lymphoma
- saline siuresis @ ~6ml/kg/hr provided no contra-indications
- once rehydrated, furosemide to ^ calciuresis
> calcitonin and bisphosphonates v Ca
13
6 methods of monitoring lymphoma patients on chemo
1. PE to check for remission or relapse
2. haem: check myelosuppression before each tx in induction
- if neutropenia 180mg/m2 cumulative (6 cycles))
14
How can GI disturbance d/t chemo be managed?
- frequently mild and self limiting (starve 24hrs if BAR + afebrile)
> but risk of bacterial translocation if neutropenic so if unwell/pyrexic see vet
- may need IVFT
- Antiemetics (maropitant, metoclopramide, ondansetron)
- Apetite stimulants (mirtazapine, cyproheptadine)
- Metronidazole has immunomodulatory effect with D+
15
How can myelosupression d/t chemo be managed?
- prophylactic Abx if neutrophils
16
How can haemorrhagic cystitis d/t cyclophosphamide be managed?
- switch to chlorambucil or melphalan
- can be severe and slow to resolve, sometimes irreversible
> Tx:
- NSAIDs if not on steroids
- Oxybutinin antispasmodic
- GAGs
> prevention
- ^ water intake, give drugs morning
- consider dividing into 2 doses
- give furosemide concurrently
17
How does allergic reaction present in cats and dogs. How can hypersensitivity/allergic reactions be managed ? Which drugs may cause this?
- L-asparaginase and doxorubicin
- Dogs: urticarial, oedema, hyperaemia, VD+
- Cats: respiratory distress, vomiting
> stop drugs, give antihistamine and dexamethasone
18
How should extravasation of chemo agents be managed?
* Serious!* can need amputation
- leave catheter in place, attempt to withdraw as much as possible
- doxorubicin ICE
- vincristine HEAT
> specific drugs can be given under specialist advice
- doxorubicin: dexrazoxane IV
- vincristine: hyaluronidase locally
> antiinflam doses of dex IV and topical steroid cream
19
For dogs with multicentric lymphoma, How does remission rate compare for no tx, pred only, COP and CHOP?
- n/a
- 33%
- 70-80%
- 80-94%
20
For dogs with multicentric lymphoma, How does first remission duration compare for no tx, pred only, COP and CHOP?
- n/a
- 1mo
- 3-6mo
- 9mo
21
For dogs with multicentric lymphoma, How does survival time compare for no tx, pred only, COP and CHOP?
-
22
For cats with high grade lymphoma, how does remission rate compare for no tx, pred only, COP and CHOP?
- n/a
- n/a
- 50-80%
- 50-70%
23
For cats with high grade lymphoma, how does first remission time compare for no tx, pred only, COP and CHOP?
- n/a
- n/a
- 3-8mo
- 4mo
24
For cats with high grade lymphoma, how does survival time compare for no tx, pred only, COP and CHOP?
- 4-6weeks
- n/a
- 3-10mo
- 3-10mo
25
What is the 1 year survival % of cats with high grade lymphoma?
30%
26
What is the 2 year survival rate for dogs with multicentric lymphoma?
20-25%
27
Prognosis for GIT specific lymphoma in cats
> low grade
- small cell, lymphocytc T cell
- good prog
- chlorambucil and prednisolone
- 70% complete response, MST >2year
> high grade
- lymphoblastic B or Large T cell shorter MST 3-10mo
- large granular lymphocytic (LGL) subtype v poor prog (30% response, MST 1-2mo)
28
Prognossis for GIT speicfic lymphoma in dogs
- poor prog (MST ~77d, 6-700 range)
- except colorectal form with longer survival if COP/CHOP used
29
Prognosis for localised nasal lymphoma in cats
- tx radiation : good response
- most respond, MST 1.5-3y in responders
30
Negative prognostic indicators for lymphoma in dogs
- high grade T cell (except one subtype newly discovered with good prog) MST 1/2 that of B cell (ie. 6mo with CHOP)
- clinical substage b
- Hypercalcaemia (more likely with T cell phenotype)
- BM invovlement (stage V)
- prolonged pretx with corticosteroids
- failure to acheive complete remission
- site: GIT/renal/pure hepatosplenic lymphoma
31
Negative prognositc indicators for lymphoma in cats
- failure to acheive complete remission
- FELV + status
- High grade
- LGL (large granular lymphocyte) rare variant
32
What are leukaemias?
- malignant neoplasia originating from haematopoietic precursor cells in BM (or sometimes spleen)
- neoplastic cells MAY be present in circulation
- sometime proliferate in BM but do not spill out so only cytopenias sen (ALEUKAEMIC LEUKAEMIA)
33
What are the 2 main categories of leukameias?
- lymphoid v myeloid
- acute v chronic
34
What is acute leukaemia characterised by?
- aggressive biological behaviour
- dz progression rapid with severe clinical signs
- immature blast cells in marrow.blood, poorly differentiated, high capacity for rapid cell division
* POOR PROG*
35
What is chronic leukaemia characterised by>
- slow progression
- clinical signs mild or incidental finding
- neoplastic cells well differentiated late precursor cells, with lesser capactiy for division
- *PROG REASONABLE*
36
What are the 2 forms of lymphoid leukaemia?
ALL and CLL
37
Which form of lymphoid leukaemia is not easily differentiated from stage V lymphoma? How do these disease differ? How can they be differentiated?
> ALL (disease starts in the marrow)
- sicker
- more profound cytopenia on haem
- milder lymphadenomegaly
> lymphoma (disease starts peripherally and spreads to marrow)
- to differentiate use flow cytometry (ALL cells + for CD34 marker of immature haematopoietic stem cells)
38
Which has a worse prognosis, ALL or stage V lymphoma?
ALL
39
What are myeloproliferative disorders?
- neoplastic AND pre-/non-neoplastic conditions of all the non-lymphoid cells in the marrow
- uncommon and not well hcaracterised in dogs and cats
> acute myeloid leukaemias: undifferentiated leuk, myeloblastic leuk, myelomonocytic leuk, monoblastic leuk, megakaryoytic leuk, erythroleuk, subtypes
> myeloproliferative neoplsms/chronic myeloproliferative disorders: chronic myelogenous leukaemia, eosinophilic and basophilic leuk, 1* thrombocytosis (essential thrombocythemia, polycythaemia vera)
> others: myelofibrosis, myeoldysplasia
40
Clinical signs of leukaemia?
- non specific wt loss, lethargy, malaise, anorexia, GI signs, mild generalised lymphadenopathy, hepatosplenomegaly
- signs related to myelopthisis - fever, petechial haemorrhage, pallor, +- hypercalcaemia
41
How can leukaemias be diagnosed?
- if abnormal cells circulating flow cytometry distinguishes particular cellt ype invovled
- may require BM aspirate +- core
42
Tx acute leukaemias. Px?
> poor response rate and px (ALL: 30% response, MST 120d in dogs, response same in cats remission may last longer)
> AML similar px
- pre-existing cytopenias cause problems as chemo drugs myelosuppressive ^ risk sepsis/haemorrhage
> Tx ALL : potentially use same drugs as lymphoma
- start with L-asparaginase and pred as less myelosuppressive
> Tx AML
- try cytosine arabinoside (no one knows how to tx this!)
43
Tx chronci leukaemias? Px?
> much better success rate and px!
> CLL : affects older animals,
- tx chlorambucil and pred (MST 1-3yrs)
> CML : rare
- tx hydroxycarbamide (hydroxyurea)
- MST 4-15months
44
What is myeloma?
plasma cell tumour affecting BM in older animals
45
Clinical signs of myeloma. Dx tests and results seen...
- mild pyrexia, lethargy, palor
- mild generalised lymphadenopathy
- hepatosplenomegaly
- signs of hyperviscosity (eg. neuro, retinal detachment, bleeding tendencies, lameness/bone pain d/t lytic lesions in bone esp flat bones)
> haem: mild non-regenerative anaemia, cytopenia
> biochem: hyperglobulinaemia d/t Ab production by plasma cells (monoclonal spike on serum protein electrophoresis +- hypercalcaemia
> radiographs: punched osteolytic lesions (vertebrae, pelvis, long bones) uncommon in cats, or diffuse osteopenia
> urine: bencejones light chains proteinuria/ similar pattern to serum if electrophoresis carreid out
46
How can myeloma be dx?
BM aspirate/biopsy showing increased numbers of plasma cells
47
Tx myeloma?
DOGS - Melphalan and prednisolone (MST ~12-18mo dogs)
CATS - Melphalan -> marked myelosuppression so use chlorambucil and prenisolone
48
Px myeloma?
Worse in cats
MST 12-18mo in dogs
49
What is polycythaemia vera?
1* erythrocytosis
- proliferation of erythroid cell series in marrow, with differentiation to RBCs
50
CLiical signs of polycythaemia vera? DDx?
- bright red MMs
- neuro signs d/t hyperviscosity of blood
- persistently high PCV (65-85%) + low/normal EPO activity
> Ddx
- differnetiate from dehydration
- appropriate causes of ^ PCV (hypoxia)
- EPO producing tumours
51