Flashcards in Haematopoetic Neoplasia 2 (Annaleise Stell) Deck (51):
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.
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
Is chemo curative for lymphoma?
No remission not cure, will relapse
What protocol are available for tx lymphoma?
- cyclophosphamide , vincristine, prednisolone
- induction phase + ongoing oral maintainance (chlorambucil, methotrexate, prednisolone)
- doxorubicin containing
- more intensive initially, longer induction
- no maintainance
- 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
What adverse effects may lomustine have?
hepatotoxic so monitor SAMe
Which cat lymphomas is cytosine arabinoside useful for?
- CNS (cytarabine crosses BBB)
Standard maintainance for cats
- chlorambucil and prednisolone EOD
How is low grade feline GI lymphoma tx?
> oral only, few side effects
- Chlorambucil [Leukeran]
(- can use cyclophosphamide or lomustine if relapse)
Outline a low budget protocol for tx lymphoma
- Prednisolone alone
- Prednisolone + chlorambucil (monitor haem)
- Lomustine +- prednisolone (monitor carefully for myelosuppression, hepatotox)
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
Are resuce tx often successful?
Less successful than 1* induction
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
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))
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+
How can myelosupression d/t chemo be managed?
- prophylactic Abx if neutrophils
How can haemorrhagic cystitis d/t cyclophosphamide be managed?
- switch to chlorambucil or melphalan
- can be severe and slow to resolve, sometimes irreversible
- NSAIDs if not on steroids
- Oxybutinin antispasmodic
- ^ water intake, give drugs morning
- consider dividing into 2 doses
- give furosemide concurrently
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
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
For dogs with multicentric lymphoma, How does remission rate compare for no tx, pred only, COP and CHOP?
For dogs with multicentric lymphoma, How does first remission duration compare for no tx, pred only, COP and CHOP?
For dogs with multicentric lymphoma, How does survival time compare for no tx, pred only, COP and CHOP?
For cats with high grade lymphoma, how does remission rate compare for no tx, pred only, COP and CHOP?
For cats with high grade lymphoma, how does first remission time compare for no tx, pred only, COP and CHOP?
For cats with high grade lymphoma, how does survival time compare for no tx, pred only, COP and CHOP?
What is the 1 year survival % of cats with high grade lymphoma?
What is the 2 year survival rate for dogs with multicentric lymphoma?
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)
Prognossis for GIT speicfic lymphoma in dogs
- poor prog (MST ~77d, 6-700 range)
- except colorectal form with longer survival if COP/CHOP used
Prognosis for localised nasal lymphoma in cats
- tx radiation : good response
- most respond, MST 1.5-3y in responders
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
Negative prognositc indicators for lymphoma in cats
- failure to acheive complete remission
- FELV + status
- High grade
- LGL (large granular lymphocyte) rare variant
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)
What are the 2 main categories of leukameias?
- lymphoid v myeloid
- acute v chronic
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*
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*
What are the 2 forms of lymphoid leukaemia?
ALL and CLL
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)
- 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)
Which has a worse prognosis, ALL or stage V lymphoma?
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
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
How can leukaemias be diagnosed?
- if abnormal cells circulating flow cytometry distinguishes particular cellt ype invovled
- may require BM aspirate +- core
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!)
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
What is myeloma?
plasma cell tumour affecting BM in older animals
Clinical signs of myeloma. Dx tests and results seen...
- mild pyrexia, lethargy, palor
- mild generalised lymphadenopathy
- 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
How can myeloma be dx?
BM aspirate/biopsy showing increased numbers of plasma cells
DOGS - Melphalan and prednisolone (MST ~12-18mo dogs)
CATS - Melphalan -> marked myelosuppression so use chlorambucil and prenisolone
Worse in cats
MST 12-18mo in dogs
What is polycythaemia vera?
- proliferation of erythroid cell series in marrow, with differentiation to RBCs
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
- differnetiate from dehydration
- appropriate causes of ^ PCV (hypoxia)
- EPO producing tumours