Haematopoetic Neoplasia 2 (Annaleise Stell) Flashcards Preview

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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

Tx polycythaemia vera?

- phlebotomies
- replacment of blood with colloids/electrolytes to alleviate hyperviscosity
- hydroxycarbamide (hydroxyurea)