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1

Veterinary hematopoietic neoplasia a comparative (re)view

Dr Maurice Zandvliet, DVM, MVR, PhD, Dipl ECVIM-CA [Med & Onc]

8 september 2015

Assistant professor, Medical and Radiation Oncologist

UU Animal Cancer Centre Department Clinical Sciences of Companion Animals

Faculty Veterinary Medicine, Utrecht University

How common are hematopoietic tumors?

Localisation Standardized incidence rate

(/100.000 insured dogs/year UK)

1. Skin and subcutis 1.437

2. Gastrointestinal tract 210

3. Mammary glands 205

4. Urogenital system 139

5. Lymphoid organs and bone marrow 134

6. Endocrine organs 113

7. Oral and pharyngeal cavity 112

8. Bone 83

9. Nasal cavity and Respiratory tract 32

10. Central nervous system (incl eye) 26

11. Other (incl heart) 3

Dobson et al, 2002

107/134 cML

Definitions

Disease presentation

Leukemia

• Acute/poorly differentiated

• Chronic/well differentiated

Mass-lesion

• Lymphoma

• Mast cell tumor

• Plasmacytoma

• Histiocytic sarcoma

• Often both presentations exist

Cellular origin

Myeloid/Non-lymphoid

• Erythrocytes

• Granulocytes

• Thrombocytes

• Mast cells

• Histiocytes/Monocytes/

Macrophages

Lymphoid

• Lymphocytes

• Plasma cells

So, what‘s out there?

Erythrocytes

Erythroblastic leukemia

Polycythemia vera (PCV)

Granulocytes

Acute myeloid leukemia (AML)

Chronic myeloid leukemia (CML)

Myelodysplastic syndrome

Hypereosinophilic syndrome

Thrombocytes

Megakaryoblastic leukemia

Essential thrombocytosis

Lymphocytes

Acute lymphoblastic leukemia (ALL)

Chronic lymphocytic leukemia (CLL)

non–Hodgkin lymphoma

Lymphomatoid granulomatosis

Plasma cells

Plasma cell leukemia

Extrosseous plasmacytoma (cutaneous, mucosal)

Sollitary osseous plasmacytoma

Multiple myeloma

Mast cells

Mast cell leukemia

Mast cell tumor ((sub)cutaneous, mucosal,

visceral)

Histiocytes/Macrophages

Dendritic cell leukemia

Histiocytoma

Langerhans cell histiocytosis (cutaneous,

pulmonary)

Reactive histiocytosis (cutaneous, systemic)

Histiocytic sarcoma (localized, disseminated)

Hemophagocytic syndrome

So: let’s focus on B-cell diseases…

Küppers et al, 2005

Oncogenic pathways

Basso & Dalla-Favera, 2015

Human vs Veterinary

Differences

• Use of cytology over histology

• Limited use of immunophenotyping,

flow cytometry/FACS, cytogenetics, (PET-)CT-scan

• Limited role of immunotherapy

Reasons • Ethical grounds • Technical limitations • Therapeutic limitations • Financial restrictions

Similarities • Comparable diseases ± • Comparable diagnostic modalities including cytology, histology,

IHC, Rx, US, CT, MRI, scintigraphy, CGH, canine BAC-probes • Comparable treatment options including Sx, CTx, RTx, BM and/or

peripheral stem cell transplantation

Thomas et al, 2003

Canine lymphoma

Exact incidence uncertain (underreported)

• ±6% of all canine neoplasias • 90% of all canine hematopoietic neoplasias

Estimated annual incidence rate

• 1960s: 13-24 per 100.000 dogs • 2000s: 107 per 100.000 dogs

Risk factors • Hormonal (F lowest risk OR 0.69) • Viral (EBHV) • Environmental

- waste incinerators, polluted sites, radioactive waste • Genetic

- breed predisposition, family/clustering, Glutathione-S-Transferase, reduced DNA-repair capacity in GR

cML/Epidemiology & Etiology

Shar-Pei Mastocytoma

Scottish Terrier TCC, Lymphoma,

Melanoma

Rottweiler Osteosarcoma,

Lymphoma

Mopshond Mastocytoma

Labrador Retriever Lymphoma,

Hemangiosarcoma

Greyhound Osteosarcoma

Golden Retriever Lymphoma,

Hemangiosarooma

Flat-coated Retriever Histiocytair Sarcoma,

Melanoma

English Springer Spaniel Mammary gland

carcinoma

Collie Nasal carcinoma

Cocker Spaniel Lymphoma

Chow Chow Gastric carcinoma

Great Dane Osteosarcoma

Bernese Mountain dog Histiocytic Sarcoma,

Lymphoma, Mastocytoma

Boxer Lymphoma, glioma,

Mast cell tumor

Canine cancer/Breed

cML/Breeds

Modiano et al, 2005 Pastor et al, 2009 B T

Clinical signs are highly variable depending on: • Anatomical tumor location • Presence of paraneoplastic syndromes (PTH-rp)

cML/Signs

- Painless, generalized lymphadenopathy

- Lethargy - Reduced appetite - Weight loss - Pu/Pd - Fever - Skin/mucous membrane lesions

- GI-signs (vomiting/diarrhea) - Ocular manifestations - Immune-mediated disorders - Jaundice - CNS-signs - Dyspnea - Ocular manifestations - Caval syndrome

cML/Diagnosis - Radiography

Cranial mediastinal mass Interstitial infiltrates

cML/Diagnosis - Ultrasonography

Abdominal lymph node Spleen

cML/Diagnosis - CT-scan

cML/Cytology

Intermediate/High grade Low grade

cML/Diagnosis - PARR

The VDJ gene encodes the antigen‐binding region of the antibody

cML/Diagnosis - PARR

PARR = PCR Antigen Receptor Rearrangement

• VDJ region is amplified by PCR and products are separated by size on a sequencer

• Clonality assessments uses the size of the antibody gene to determine if a neoplastic B cell or T cell is present

• A single sized product indicates malignancy

Reactive B-cell ML T-cell ML

cML/Immunocytochemistry

CD79a/Pax5 B-cell

CD3+ T-cell

cML/Classification

cML/Histology - classification

Seelig et al, 2016

cML/Histology - classification

Seelig et al, 2016

cML/B vs T, High vs Low?

Frantz et al, 2009

4-gene signature profile CD28/ABCA5 = B vs T

CCDC3/SMOC2 = T_high vs T_Low

qRT-PCR on lymphoma samples

cML/cDLBL – ABC vs GCB?

human ABC/GCB classifier genes cDLBCL “canine-specific” ABC/GCB classifier genes

Richards et al, 2013

cML/cDLBL – ABC vs GCB?

• No BCL-6 detected with IHC in cDLBCL • BCL-6 mRNA present, expression not prognostic • Hans and Choi algorithms do not work in cDLBCL

• Clear activation of NF-κB in high percentage of cDLBCL • High expression of Bcl-2 and cMYC

• Suggestive that cDLBCL is ABC‐ like

• (Epi)genetics • limited genomic instability compared to hDLBCL • no evidence for CDKN2A/B deletion • genomic hypomethylation in majority of cML cases • microRNAs

cML/Chemotherapy

Chemotherapy protocols n

dogs PL (w)

CR (%)

Median DFP

(days)

Median OST

(days)

1-year Survival

(%)

2-year Survival

(%)

P 49 Ind 43 53 NR NR NR

H (continuous) 21 15 76 206 266 NR NR

H (intermittent) 18 5x 78 81 171 NR NR

CCNU, P 17 15 35 40 111 NR NR

COP 20 Ind 70 100 224 NR NR

LCO + methotrexate 147 Ind 77 140 265 25 NR

LCHOP 68 78 65 274 301 40 21

LCHOP (VELCAP-SC) 94 21 70 168 302 44 13

LCHOP + methotrexate (UWM) 55 135 84 220 303 52 24

LCHOP (UWM- S) 51 25 94 282 397 NR NR

L = L-asparaginase, C = cyclophosphamide, H = hydroxydaunorubicin/doxorubucin, O = oncovin/vincristine, P = prednisolone

KM survival curves of dogs (n=456) with various subtypes of lymphoma

Valli et al, 2013

cML/Prognosis - Histology

Frantz et al, 2012

cML/Rescue treatment

Protocol

n ORR (%)

RR (days)

CRR (%)

CR (days)

Actinomycin D 49 41 129 41 129

Mitoxantrone 44 41 127 30 NR

Dacarbazine 40 35 43 3 144

CCNU 43 27 86 7 110

Dacarbazine, doxorubicin 15 53 45 33 105

MOPP 117 65 61 31 63

DMAC 54 72 61 44 112

LOPP 44 52 106 27 112

L-Asparaginase, CCNU, prednisolone

48 77 70 65 90

CCNU – Dacarbazine 57 35 62 23 83

cML/Other treatment options

• Radiotherapy - Localized: nasal, oral, cutaneous - Multicentric: 2x HBI

• Surgery

- Isolated low-grade splenic MZL - stage 1 multicentric

• Immunotherapy

- vaccination autologous HSP, dTERT - monoclonal antibodies (CD20)

• Targeted therapy (TKIs)

- Masitinib (cutaneous)

• Differentiating agents - Retinoids (cutaneous)

Ekita, Border collie, FN, 9yrs

• Presented for post-operative RTx following incomplete resection STS

distal LF limb

• No signs, normal pre-anesthetic exam

Ddx: hypoadrenocorticism, thymoma, post-vaccination young animals, chronic antigenic stimulation (inflammatory disorders, infections)

(cat: stress, hyperthyroidism)

160614

Reference

HCT 0.44 0.42 – 0.61

WBC 59.9 4.5 – 14.6

Neutrophils 4.8 2.9 – 11.0

Lymphocytes 54.5 0.8 – 4.7

Monocytes 0.6 0.0 – 0.9

Thrombocytes 287 144 - 603

Ekita, Border collie, FN, 9yrs

Treatment: • Chlorambucil: 0.2 mg/kg 1dd, after 7 days 0.1mg/kg 1dd PO • Prednisolone: 7 days 30 mg/m2 1dd, 7 days 20 mg/m2 1dd, then 10

mg/m2 EOD PO

160614

Reference

HCT 0.44 0.42 – 0.61

WBC 59.9 4.5 – 14.6

Neutrophils 4.8 2.9 – 11.0

Lymphocytes 54.5 0.8 – 4.7

Monocytes 0.6 0.0 – 0.9

Thrombocytes 287 144 - 603

160614

270614

250714 Reference

HCT 0.44 0.42 0.40 0.42 – 0.61

WBC 59.9 21.8 12.6 4.5 – 14.6

Neutrophils 4.8 17.7 11.1 2.9 – 11.0

Lymphocytes 54.5 2.8 0.6 0.8 – 4.7

Monocytes 0.6 1.3 0.7 0.0 – 0.9

Thrombocytes 287 383 366 144 - 603

160614

270614

250714 060716 Reference

HCT 0.44 0.42 0.40 0.43 0.42 – 0.61

WBC 59.9 21.8 12.6 13.6 4.5 – 14.6

Neutrophils 4.8 17.7 11.1 11.7 2.9 – 11.0

Lymphocytes 54.5 2.8 0.6 1.6 0.8 – 4.7

Monocytes 0.6 1.3 0.7 0.1 0.0 – 0.9

Thrombocytes 287 383 366 467 144 - 603

Canine CLL - Prognosis

Williams et al, 2008

(n = 12) (n = 17) (n = 33) (n = 34)

Canine CLL - Prognosis

Williams et al, 2008

CD21+ cell size: Small vs large : >1.000d vs 129d

CD8+ cell count: <30.109/L vs >30.109/L : 1.098d vs 131d

Loss of CD45 no effect on OST

Canine plasma cell neoplasia

A. Localized forms

• (muco)cutaneous plasmacytoma (skin, mouth, rectum) • solitary osseous plasmacytoma (SOP)

B. Systemic forms • (Plasma cell leukemia) • Multiple myeloma

• Monoclonal expansion of plasma cells • 8% of all hematopoietic neoplasias • Middle-aged to older animals (8-9 yrs) • Etiology: unknown (chronic antigenic stimulation?) • Monoclonal gammopathy

• IgG = IgA • Occasionally biclonal, “non-secretory”, IgM (Waldenströms

macroglobulinemia)

Solitary plasma cell tumors

Oral PCT Solitary Osseous PCT

Multiple Myeloma

Signs

• Often aspecific

• Infiltration of organs/bone marrow

• Paraproteinemia

Associated conditions

• Hemorrhagic diathesis (thrombocytopenia,

thrombocytopathy, hyperviscosity, hypertension)

• Hyperviscosity sydrome

• IgA dimerization, IgM • CNS, cardiac, ocular signs

• Hypercalcemia (±20%)

• Bone lesions

• Infections (opportunistic)

• Renal disease

Venous dilatation with tortuous vessels

Retinal hemorrhage

Multiple Myeloma - Diagnosis

Bence-Jones proteinuria (exclude infectious diseases)

Multiple Myeloma - Prognosis

Treatment

• Melphalan: 10 days 0.1 mg/kg 1dd PO, after that 0.05 mg/kg 1dd PO

• Prednisolone: 1 mg/kg 1dd, if in CR gradually tapered and stopped at D60

• (Cyclophosphamide)

Prognosis

• OST 540 days

• Prognostic factors: • Negative: response to CTx, hypercalcemia, Bence Jones proteinuria,

extensive osteolytic lesions • No effect: sex, Ig-subclass, hyperviscosity, azotemia

• Most dogs die from disease-related problems

Challenges or chances for veterinary oncology?

Oral squamous cell carcinoma

One health

http://www.eurolupa.org/

“Sequencing the dog genome will facilitate the identification of genes that may provide explanations for the vast range of mammalian variation and help us to better understand the

genetic basis of diseases common to both human and dog. The breed chosen for sequencing is the boxer, which is one of the

breeds with the least variation in its genome.”

One health