Lymphoma Diagnosis With Unusual Presentation

[kudzu]

Up front. before the long message that follows, I'll ask the main question. Does any of this sound normal for lymphoma? So far none the lymph nodes enlarged, and by now there are countless numbers of them, are the ones we normally think of. That being neck, behind knees, arm pits, etc. Vet referred to diffuse lymphatic inflammation. He felt it was likely to be lymphoma but said he's never seen anything like it. Pathology reports of FNA confirmed lymphoma. Now here's the story:

____________________

 

My staghound was diagnosed with lymphoma yesterday. Sunday morning I noticed a large, flat lump on her side, right, lower ribcage. It had a strange shape & feel with several tendrils branching off & immediately made me nervous. However, since she had an incident a few weeks ago that appeared to be a reaction to wasp (perhaps) stings I decided not to rush her to the e-vet. (We've an overpopulation of wasps this year for some reason?) Sunday PM I found a second lump. This one was on the other side, similar though slightly lower position. It was smaller with shorter tendrils/branches. Couldn't get her in to the regular vet Mon but when I got home from work that night & felt the lumps I decided I'd rather pay extra than wait. So off to e-vet we went where I subsequently found two more lumps, one on either side, high up, just in front of her hips. Also, she had some edema in her lower neck & chest. I was freaking out then but still hoping it would be stings or some such. Evet did FNA of two spots, first lump & a newer one. First lump "appeared to be nothing but blood. Looks like a bruise." But my girl's skin didn't look bruised. Second lump "was loaded with lymphoblasts." She had a strong feeling it would be lymphoma.

 

Was at regular vet office first thing Tues AM. He did repeat FNA of old lumps & most of the 5 new lumps that had developed & edema was still there. He didn't give explanation for edema but said the lumps were all lymph nodes. Most slides were sent out to pathology. The ones he examined gave him same opinion as e-vet, lymphoma. Except... None of the enlarged lymph nodes were those usually swollen in a classic presentation of lymphoma. All the ones I would have thought to check if asked about swollen lymph nodes felt normal to him. By Tues PM I had 11 lumps on my chart for her.

 

By yesterday morning I had given up counting & this morning some of the old & new lumps have enlarged enough to meet up. In addition, the edema has increased dramatically. She suddenly looks & feels like a much bigger dog than she did three days ago. Until yesterday she was still her happy, energetic, vivacious, play-play-play self. Her subdued behavior yesterday might have been a response to all the vetting, needle jabs, stress, etc. of the prior 36 hours but I am not convinced. I am sure she is uncomfortable.

 

All else is completely normal with her. Her bloodwork 3 weeks ago was totally normal with two exceptions. She had very slightly low WBC & lymphocytes. Why would lymphocytes be low in a dog with lymphoma? We did not do urinalysis, rads or repeat bloodwork yet. Those will be done, most likely when at UGA for oncology consult. Am hoping to get her in tomorrow but I've no idea what their time frame is. I received our preadmission number too late yesterday to get an appt. Am waiting for a call back from scheduling.

 

Any of this sound like a normal presentation of lymphoma? The vet said he'd never seen anything like it & really felt we needed an oncologist. I'm looking at my little girl, only barely 3 years old, watching this THING taking over her so very, very fast & wondering if I should go plant myself on UGA's doorstep. Sadly, I know from past experience that won't work well. However, I will be on the phone to the vet as soon as they open. I'm really terrified by the rapid progression. At this rate I feel like we've less than a week. I've never dealt with lymphoma & my ... no words. I'm crumbling.

Edited August 6, 2011 by kudzu

[DaisyDoodle]

Oh my gosh, this sounds horrible and frustrating. My Cosmo had lymphoma, but it was a straightforward case.

 

If I were you I'd immediately get all slide images, blood work, etc to Dr. Couto's group at OSU. They have done studies on lymphoma there.

 

I would ask OSU and the local/university vets you're working with about starting prednisone. Unless there is a different disease that hasn't been ruled out that would react badly to prednisone, the pred would hold lymphoma and other inflamatory processes at bay 'til you/they can figure out what is going on. If the vets say you're not suppose to give pred first (before chemo) with lymphoma, ask them to contact Dr. Couto. He's written a paper on research about timing of use of pred and chemo in lymphoma cases.

 

I would also consider a chest x-ray and abdominal ultrasound. These will provide more information quickly if something really serious is going on, and will give you peace of mind if they are both normal.

 

The only other disease that comes to mind is cutaneous hemangiosarcoma, which is not as dangerous as the internal kind. (Note-I'm not a physician, don't play one on tv...) Not sure if the symptoms and labs would point that way??

 

Good luck. Please keep us posted.

[Batmom]

Lymphocytes could be low because they aren't maturing properly. Hoping UGA can see the dog quickly and evaluate the diagnostics.

 

FWIW, here is a nice review of diagnostics for lymphoma vs. other things: http://www.cldavis.org/cgi-bin/download.cgi?pid=29 .

 

Sending lots of prayers that it's something else, and benign!

[MaryJane]

Did they run any cultures to rule out bacterial involvement?

 

edited to add - I'm guessing that another reason (pretty far out) if the dog was fighting a bad viral infection it could cause the blood levels to be decreased and for "immature cells" to be released from the bone marrow. Not sure why they would be collecting in lumps on the skin - any chance that there are "stings" from the wasps at the location of the lumps? Again - this is pretty far out but, just throwing it out there ....

Edited August 4, 2011 by MaryJane

[Guest goofydog]

Holy crap Laura. I don't have any insight but wanted to let you know that Luna(tic) is in my prayers. She's such a hoot and I love her very much. Hugs for you also. Please let me know if you need any help with your other critters while you're on the road with Luna.

 

 

[TheFullHouse]

Pat (PhillyPups) had one of her's come down with lymphoma who had those raised bumps come up over night and spread like that.

[JJNg]

Unfortunately, it sounds like cutaneous lymphoma, which is a pretty rare presentation of the disease, and also carries a worse prognosis. I remember seeing a case when I was in vet school (at UGA). Hopefully, there have been some new advances in treatment since then. If you still haven't heard back from UGA, maybe you can try calling again. With as quickly as it sounds like it's progressing, maybe you (or your vet) can impress on them the urgency of getting her seen asap.

 

Cutaneous lymphoma is such a rare condition that I wasn't able to find any really good, comprehensive articles, but there were a few that I did find:

 

http://www.ehow.com/about_6618649_epithelial-cutaneous-lymphoma-dog.html

http://www.mypetsdoctor.com/canine-cutaneous-lymphoma

http://carevets.co.nz/?p=146

[kudzu]

Thanks, everyone. UGA couldn't get us an appt until Thurs next week. I was freaking out, as you could tell from my post. Called my vet & she got us in at a different clinic with an IM/Onco vet I'd consulted before concerning my late Luke's CLL. They called me minutes after I hung up with my vet. Luna & I were in their doors an hour later. Big sigh of relief. No it isn't UGA's oncology dept with as far as I can tell has a good reputation but Luna will be much less stressed out there. I trust & feel very comfortable with this vet. Which means a lot. Most of all, we will be finished with staging, know the type before I could have had the first consult with UGA. If I can be convinced that is the best option, Luna could start chemo next Thurs or Friday.

 

Want to clarify something, especially since I made sure to verify it with the onco vet yesterday. These lumps are under the skin, not in it. She said these are subcutaneous not cutaneous. Asked if these are really lymph nodes & she responded it would be better referred to as lymphoid tissue. And still all the classic lymph nodes we associate with lymphoma remain of normal size with Luna. She also echoed something I was already worried about based on my limited research. She is concerned this type of presentation is more likely to be T cell which has a much worse prognosis than B cell. (Jjing I think this is different than what you are referring to but not necessarily much better prognosis. ???) We won't know until the immunophenotyping results return next week.

 

The good news is that rads, ultrasound & urinalysis are normal. We're rerunning the CBC & blood chem from a few weeks ago. Results will be back Monday but am not anticipating any change. The bad news is there is nothing to help her between now & next week. Lumpy Luna will keep getting lumpier & that just terrifies me. For ages I've been saying I wanted a little more padding on my skinny, bony girl. I must remember to be more specific when making wishes. This is NOT what I meant. We won't be using prednisone for Luna because of the risk of demodecosis. Demodex first cropped up, in sudden, spectacular fashion, when she was one. We could just never clear it.

 

Demodex is one reason I am hesitant about chemo. Another is because though Luna isn't prone to infection, once she gets one her body has great difficulty fighting it. The only two times she's gotten an infection, from a puncture wound & secondary to demodecosis, those went raging through her system requiring emergency care. The first one, even though already started on antibiotics for four days prior, had her admitted to hospital for 60 hrs on iv antibiotics, with 36+ hrs on chilled iv's because of the fever. (She has a littermate with similar problems. Per the veterinarian who adopted her that dog's "immune system just isn't up to snuff.") What happens to a dog like this undergoing chemo? If we did chemo it would be modified Wisconsin. Didn't even think to ask how pulling out pred will effect the protocol. I know nothing of chemo & protocols.

 

DaisyDoodle: Would the OSU program consult on a staghound? She's is basically a Deerhound. Dad though was Greyhound/Borzoi.

[DaisyDoodle]

Regarding OSU--I'm pretty sure that they'd be willing to help any sighthound, but I recommend that you get in touch with JoeJoesMom, who lives near OSU and has regular contact with them.

 

Regarding chemo--yes chemo will definitely blast the immune system. The vets will do blood work before each treatment, I believe to check both the white cell and red cell counts. I would ask for any kind of immune booster that is available. I'd also ask about doing prophylactic antibiotics if they won't screw up other things. If you add those, I'd also add yogurt and/or probiotics to keep the good flora happy.

 

My CoCo was on the modified Wisconsin protocol for a year, then we settled on a "salvage" (secondary) protocol of CCNU for the second year. From the time I found her nodes enlarged she lived 28 months, and went to the Bridge primarily because I mismanaged her long-term prednisone dosing--a long story I can tell you another time.

 

Is there a reason the vet won't start your boy on prednisone right away? Short-term, proper use of this drug can be effective.

 

I'd also ask the vet and OSU about CCNU as a first-course treatment. It's a pill, and the side effects were mild compared to some of the components of the modified Wisconsin profile, IIRC.

 

Be sure, too, to make sure that the vet is familiar with "sighthound dosing". The vet who treated CoCo was very conservative with both protocols compared to what the standards called for.

[kudzu]

My CoCo was on the modified Wisconsin protocol for a year, then we settled on a "salvage" (secondary) protocol of CCNU for the second year. From the time I found her nodes enlarged she lived 28 months, and went to the Bridge primarily because I mismanaged her long-term prednisone dosing--a long story I can tell you another time.

I am sorry about the final outcome but very glad CoCo had that extra time with you.

 

Is there a reason the vet won't start your boy on prednisone right away?

Too much risk of demodecosis. Besides just the discomfort & damage from the demodex there is the specter of secondary infection.

 

I'd also ask the vet and OSU about CCNU as a first-course treatment. It's a pill, and the side effects were mild compared to some of the components of the modified Wisconsin profile, IIRC.

 

Be sure, too, to make sure that the vet is familiar with "sighthound dosing". The vet who treated CoCo was very conservative with both protocols compared to what the standards called for.

Thank you for bringing that up. The possible variation in protocol for a sighthound is the main reason I asked about OSU. I will check on both.

[JJNg]

Glad you were able to get her in to see an oncologist today. I find that the private practice specialists tend to be a lot more efficient than the vet schools anyway, and they are usually just as qualified.

 

Tried to do a search for subcutaneous lymphoma, and not finding much although there are some reported cases on the vet message boards. Seems like it may be even more unusual than the cutaneous form, and the general consensus is that most atypical presentations tend to be more aggressive.

 

Luna's history of demodecosis and the suspicion of immune dysfunction (possibly even related to her cancer at such a young age?) is certainly a concern when considering treatment options. However, if you were inclined to give it your best shot to fight this, chemo may be your only option. Without treatment, even the typical presentation of lymphoma progresses rapidly. At least knowing her predisposition to infections, you can either start prophylactic treatment or be extra vigilant to catch any problems asap. The way I see it, the lymphoma is a certainty, while the recurrence of demodex or infection are possibilities (even though they may be strong possibilities).

 

Given that pretty much any chemo agent suppresses the immune system to some degree, if you do opt for chemo, is it really worthwhile to avoid pred because of her demodex history? Are the other chemo drugs less likely to trigger a recurrence than pred? I honestly don't know the answer to this and would be curious what the oncologist says. Sending good thoughts to both you and Luna.

[kudzu]

Seems like it may be even more unusual than the cutaneous form, and the general consensus is that most atypical presentations tend to be more aggressive.

 

This is the impression I have as well though that comes from human med. It also seems that lowered or compromised immune systems are one of the primary risk factors for developing this sort of cancer.

 

Given that pretty much any chemo agent suppresses the immune system to some degree, if you do opt for chemo, is it really worthwhile to avoid pred because of her demodex history? Are the other chemo drugs less likely to trigger a recurrence than pred? I honestly don't know the answer to this and would be curious what the oncologist says.

I don't know either. Demodex & her previous inability to deal well with infections is why I am so hesitant about chemo. Her comment that we would not be using pred as part of the protocol surprised me. Oh, she did later qualify it. We will probably not use pred. Though it makes sense, I had not even thought of it and I will be interested in hearing why it is worse than other drugs in the protocol. If I thought the chances of achieving remission with similar duration as the more common B-cell lymphoma it would be a much easier decision. But with something my gut tells me is not likely to same rules as classic canine lymphoma I just don't know if it is worth risking making her sicker through chemo or pred. Would prefer a more peaceful, well planned departure than one in the e-vet, hooked up to iv's.

 

We will see what the upcoming days bring as the last of the results come in. I do know that we are better off for getting started sooner rather than later. Thank you so much for the info you've provided. Though it doesn't offer any better hope it does help & that is truly appreciated.

 

PS She still LOVES to play in sand like she did in the driveway at the polo field. I think perhaps I should get a little wading pool & fill it with sand, post haste.

Edited August 6, 2011 by kudzu

[MerlinsMum]

I have no experience with this or veterinary knowledge, but I just wanted to send you some hugs. I'm thinking of you and Luna.

[Guest zoolaine]

Seems like it may be even more unusual than the cutaneous form, and the general consensus is that most atypical presentations tend to be more aggressive.

 

This is the impression I have as well though that comes from human med. It also seems that lowered or compromised immune systems are one of the primary risk factors for developing this sort of cancer.

 

Given that pretty much any chemo agent suppresses the immune system to some degree, if you do opt for chemo, is it really worthwhile to avoid pred because of her demodex history? Are the other chemo drugs less likely to trigger a recurrence than pred? I honestly don't know the answer to this and would be curious what the oncologist says.

I don't know either. Demodex & her previous inability to deal well with infections is why I am so hesitant about chemo. Her comment that we would not be using pred as part of the protocol surprised me. Oh, she did later qualify it. We will probably not use pred. Though it makes sense, I had not even thought of it and I will be interested in hearing why it is worse than other drugs in the protocol. If I thought the chances of achieving remission with similar duration as the more common B-cell lymphoma it would be a much easier decision. But with something my gut tells me is not likely to same rules as classic canine lymphoma I just don't know if it is worth risking making her sicker through chemo or pred. Would prefer a more peaceful, well planned departure than one in the e-vet, hooked up to iv's.

 

We will see what the upcoming days bring as the last of the results come in. I do know that we are better off for getting started sooner rather than later. Thank you so much for the info you've provided. Though it doesn't offer any better hope it does help & that is truly appreciated.

 

PS She still LOVES to play in sand like she did in the driveway at the polo field. I think perhaps I should get a little wading pool & fill it with sand, post haste.

 

 

Sunny had cutaneous lymphoma last year. He went from being normal to me finding a few bumps on his rump and face to hardly being able to walk within a few days. He tried several different chemo protocols until we found one that worked for him - he then had several happy months until he passed in June 2010. He was really only sick the last few days and I would make the same choices for him again if I had to. He didn't do as well on the chemo because he had previously had steroids for GI issues - for some reason the prednisone type drugs limit the response to chemo. I know you said she doesn't fight infection well - but Sunny was on immune suppressing medication (for GI issues) and the chemo didn't bother him - fatigued and kinda blah for a day or 2 then back to himself.

[joejoesmom]

I am sure Dr. Couto would be happy to consult. Here is the link to send the request:

 

https://greyhound.osu.edu/consultationservice/

 

I know that Dr. Couto is in town (at least through next week). Especially since it is so unusual he may want to be involved in the consult.

 

Jane

[greyhead]

I have no experience with this or veterinary knowledge, but I just wanted to send you some hugs. I'm thinking of you and Luna.

Me too.