+ feline nasal lymphoma alexandra parry 3/26/2014 radiation therapy in a 10 year old domestic...
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Feline Nasal Lymphoma
Alexandra Parry3/26/2014
Radiation therapy in a 10 year old domestic shorthair
+History
10 YO FS DSH with respiratory difficulty
October 2013: upper respiratory noise; intermittent sneezing; serous, right-sided ocular/nasal discharge
November 2013: serosanguinous nasal discharge – azythromycin
December 2013: amoxicillin/clavulanic acid (Clavamox), tobramycin, cefovecin (Convenia), triamcinolone acetonide (Vetalog), cetirizine (Zyrtec)
+Physical Exam: December 27, 2013
CUHA Emergency Service – QAR
T 101.8 F, HR 180 BPM, RR 40 BPM, BCS 9/9, BW = 7 kg
No ocular discharge
Clear mucoid discharge from left nostril
Mild stertor – normal respiratory rate/effort
Patent airways bilaterally
Clear lungs
+Problem List
Chronic upper respiratory congestion
Intermittent, non-productive sneezing
Right-sided serous ocular/nasal discharge
Stertor
+Differential Diagnoses
Rhinitis: idiopathic vs. allergic
Viral: Herpesvirus vs. Calicivirus
Fungal: Cryptococcus
Neoplasia: benign vs. malignant
Foreign body
+Treatment
Cetirizine (Zyrtec) 5 mg PO q 24 h for 14 d
Recommended referral to Internal Medicine Service
Cetirizine (Zyrtec) “ineffective”
rDVM 1/1/14 Triamcinolone acetonide (Vetalog) injection Enrofloxacin (Baytril) 68 mg PO SID Prednisolone 2.5 mg PO as needed
+Physical Exam: January 7, 2014
CUHA Emergency Service – QAR
T 102.2 F, HR 120 BPM, RR 44 BPM, ~ 5% dehydrated
Right-sided soft tissue nasal mass Between dorsal nasal concha and nasal septum
Decreased air flow from right nares
Intermittent serous discharge from the left nostril
Serous ocular discharge OU
+Problem List
Chronic upper respiratory congestion
Intermittent, non-productive sneezing
Bilateral serous ocular discharge
Left-sided serous nasal discharge
Right nostril soft tissue mass
Mild dehydration
+Differential Diagnoses
Neoplasia: benign vs. malignant
Rhinitis: idiopathic vs. allergic
Viral: Herpesvirus vs. Calicivirus
Fungal: Cryptococcus
Foreign body
+Diagnostic Tests: January 7, 2014
QATS PCV 36%, TS 6 mg/dL, Azo 5-15, Glu 141 mg/dL
Gaslyte pH 7.298, pCO2 60.3 mmHg, HCO3 28 mmol/L,
Na 158 mmol/L, Cl adjusted 108 mmol/L
SpO2 94%
+Diagnostic Tests: January 8, 2014
CUHA Oncology Service
CBC
Serum Chemistry
Baseline T4
3VCXR
AUS
+Diagnostic Tests: January 9, 2014
CT/RT plan ($795.00)
PT/PTT, BMBT
Surgical biopsy submitted Undifferentiated round cell tumor T-cell-rich B-cell LSA
L R
+Re-Presented
January 12, 2014 CUHA Emergency Service BAR – T 99.9 F, HR 220 BPM, RR 44 BPM Prednisolone 5 mg PO q 24 h
January 15, 2014 CUHA Oncology Service – QAR T 101.6 F, HR 152 BPM, RR 68 BPM, ~5% dehydration
+Treatment
+Treatment
a
L R
+Treatment
a
+Treatment
a
+Treatment
3 Gy x 10 Fx = 30 Gy total dose
Prednisolone 5 mg PO q 24 h
Amoxicillin 50 mg PO q 12 h
Erythromycin ¼’’ strip OU q 8 h
+Feline Nasal Lymphoma
Nasal LSA <1% feline tumors B-cell LSA most common feline nasal cavity tumor
Median age: 10 years
Locally invasive but low metastatic rate
No agreed upon standard of care
RT and/or single and multi agent chemotherapy
+Prognosis
RT MST = 48 months
COP MST = 11 months Cyclophosphamide, vincristine, prednisone ± doxorubicin
RT + COP MST = 31 months
Prednisolone MST = 22 days
+Radiation Therapy
Definitive PalliativeLong course (16-19x) Short course (4x)Low dose High doseBetter control Less controlAcute side effects Chronic side effects Chronic side effects Acute side effects$6,000 – 7,000 $2,500 – 3,000
Disease Staging: $800-1,000
Intermediate: $3,500-4,000
+Recheck Examinations
Time Since RT Recheck Date2 weeks 2/13/144 weeks 2/27/142 months 3/30/143 months 4/30/145 months 6/30/147 months 8/30/149 months 10/30/141 year 1/30/15
+Outcome
Responded extraordinarily well
2 week recheck: 2/17/14 Minimal focal alopecia in RT field No ocular/nasal discharge or sneezing Adequate air flow, clear lungs Prednisolone 5 mg PO q 24 h
4 week recheck: 3/6/14 Prednisolone 5 mg PO q 24 h
+Summary
Difficult to diagnose
No agreed upon standard of care Owner’s financial means Treatment facility’s capabilities
Extensive radiation planning
Total Charges: $8,502.22 + 2 week recheck: $7.50 + 4 week recheck: $181.00
+Thank You
Dr. Vanessa Rizzo Clinical Science Advisor
Dr. Cheryl Balkman Basic Science Advisor
Laura Hobbs Radiation Therapy Veterinary Technician
Dr. Margaret McEntee Oncology Department Chairperson
+References
Haney, S. M., Beaver, L., Turrel, J., Clifford, C. A., Klein, M. K., Crawford, S., Poulson, J. M., & Azuma, C. (2009). Survival analysis of 97 cats with nasal lymphoma: A multi-institutional retrospective study (1986-2006). Journal of Veterinary Internal Medicine, 23, 287-294.
Little, L., Patel, R., & Goldschmidt, M. (2007). Nasal and nasopharyngeal lymphoma in cats: 50 cases (1989-2005). Veterinary Pathology, 44, 885-892.
Moore, A. (2013). Extranodal lymphoma in the cat: Prognostic factors and treatment options. Journal of Feline Medicine and Surgery, 15, 379-390.
Sfiligoi, G., Theon, A. P., & Kent, M. S. (2007). Response of nineteen cats with nasal lymphoma to radiation therapy and chemotherapy. Veterinary Radiology and Ultrasound, 48(4), 388-393.
Talaulikar, D., Dahlstrom, J. E., Shadbolt, B., Broomfield, A., & McDonald, A. (2008). Role of immunohistochemistry in staging diffuse large b-cell lymphoma. Journal of Histochemistry & Cytochemistry, 56(10), 893-900.
Taylor, S. S., Goodfellow, M. R., Browne, W. J., Walding, B., Murphy, S., Tzannes, S., Gerou-Ferriani, M., & Schwartz, A. (2009). Feline extra nodal lymphoma: Response to chemotherapy and survival in 110 cats. Journal of Small Animal Practice, 50, 584-592.
Withrow, S. J., & Vail, D. M. (2007). Small animal clinical oncology. (pp. 535-536). St. Louis, Missouri: Saunders.
+Questions
What are other acute and chronic radiation side effects?
Acute: Alopecia Moist/dry desquamation Mucositis Conjunctivitis Rhinitis KCS
Chronic: Persistent KCS Cataracts Mild chronic nasal discharge Bone necrosis New tumor in RT field
+Questions
Why were neoplasia and foreign body initially less likely? Clear nasal discharge Mild clinical signs Relative chronicity Progressive clinical signs
+Questions
How did immunohistochemistry diagnose the mass? B-cell LSA: PAX5, CD45B220, BLA36 Nodular T-cell aggregates: CD3
+Questions
What is involved in the staging procedure? General health screening: PE, CBC/Chem/UA , ± FNA 3VCXR, AUS, ± CT, ± biopsy