Nov. 11, 2022

#80: Everything you need to know about canine lymphoma. With Dr Penny Thomas

#80: Everything you need to know about canine lymphoma. With Dr Penny Thomas
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Season 1

This episode from our clinical podcast series is brought to you by the SVS Pathology Network - Australia's exclusive provider of the advanced testing techniques discussed in this episode. 

We sit down with Dr Penny Thomas from Veterinary Oncology Consultants to ask all of the questions you've ever had (and probably a few you didn't know you had!) about canine lymphoma. Dr Penny covers the common sticking points, like how to make sure you get an accurate diagnosis, new advances in diagnostic testing, a very practical way to prognosticate your lymphoma patients, what you can do for the sick lymphoma patient while you wait for the oncology appointment (spoiler alert... yes, pred!), and therapy options - from simple and cheap to going all-in on trying to achieve remission. 

Follow these links for additional information on flow cytometry and immunocytochemistry mentioned in this episode, or contact your local SVS pathologist.  

 

We're going LIVE  in Noosa on 22-25 November with the gurus of small animal medicine, Prof David Church and Prof Jill Maddison, as well a very special non-clinical day with Philip McKernan. Use VVLISTENER at checkout for our listener discount. 

 

Go to thevetvault.com for show notes and to check out our guests’ favourite books, podcasts and everything else we talk about in the show.

We love to hear from you. If you have a question for us or you’d like to give us some feedback please get in touch via email at thevetvaultpodcast@gmail.com, or just catch up with us on Instagram.

And if you like what you hear then please share the love by clicking on the share button wherever you’re listening and sending a link to someone who you think should hear this. 

 

 

His one of my favorite things about doing this podcast, when I have a pet related problem, whether it's personal, or clinical, instead of Googling, I just go, hey, I know some smart people, let's just do a podcast episode on it, that's exactly what happened a while ago when I diagnosed a lymphoma case.
One weekend at presented me with a few questions.You know, there's questions that you've had for a long time and you've never been able to get a clear answer on it.Like, is it really like really Really not.Okay for me to start the sick lymphoma dog and braids just for the weekend until she can see the oncologist next week.
When I know it's going to make you feel so much better between now and then to iPhone penny and I asked this and a bunch of other lymphoma questions that have been bothering me for a long time.We recorded this episode from those answers and it's gold.You might think, you know lymphoma, but I guarantee that there's some new stuff in your for you, but first who's painting, you'd admit, dr.
Penny Thomas That's back in episode 44 penny is the brains behind Veterinary oncology consultants and oncology service that offers remote support for vets for those tricky.Cancer cases.We've got a link to a site for you in the show description.I recommend you save it, you'll need it at some point, we released this episode a while ago, on a clinical podcast, but it's just too good not to share.
So, we bringing the full recording to you with financial support from the SVS, pathology Network, which if you're an Australian listener, you'll know better as fed bath.ASAP laboratory and qml witnessed except depending on where you work.The sba's network has 35 dedicated Veterinary Pathologists, who's beautiful brains and experience you have at your disposal to deliver your pathology results with the best turnaround times in Australia.
Now, just a quick word about our clinical podcast, I get a lot of questions along the lines of I can't find that episode that you mentioned on this or that condition I've searched all over the App Store and on Spotify, but I just can't see it.So, just to clarify, we have a totally separate stream of podcast called Fayetteville, clinical where we release, three clinical episodes per week.
Backed, by beautiful show notes, which I personally use all the time at work.You won't find the clinical podcasts on your normal podcast.If you are not subscribed, it's once you subscribe @vv in super cars.com, that's Vivian for vet wealth Network, we've got the link in the description, you can link those podcasts, your normal podcast player, and it will start popping up on your feed.
So you can listen to it wherever you like listening to podcasts.As you'll hear from this episode, they really good.It's a paid subscription.But if you need a quick and easy way to stay up-to-date, revise.The stuff that you've long since forgotten, since med school and get clarification on the Practical day-to-day questions that you don't necessarily learn in books, that I can guarantee you that it's well with it.
That's not just my opinion.That's what our subscribers tell me every day.Okay.So let's get to it, dr.Penny Thomas with everything you need to know about canine lymphoma.So, this episode happened because I had a case of lymphoma or highly suspected lymphoma on a public holiday, and I had a question and to me, it's kind of like a straightforward cancer.
You see, there's an old golden retriever 12. 13 year old came in unwell for a couple of days, not eating and when she walked in, she was skinny.And then I went to say hello to her and put her head in my hands, to give her a cuddle.And put my hands on those submandibular lymph nodes man.
That sucks is real because you know immediately Wrong in the artist.Still taking whatever.She got something mild and you mean to go?Yeah, that's cancer.My first question that I always have this little bit of doubt and I feel that and I always go.Yeah that's lymphoma and I'm talking about golf ball.Lymph nodes, not talking right?
I think there's a mild lymphadenopathy if you have that degree of lymphadenopathy all over the body.Is there anything else realistically that it can be look in Australia?It's really, really unlikely to be something else if we were Were in a different country.
Like if we were in America potentially there are some infectious diseases that they have over there that can cause a peripheral lymphadenopathy.So if you are not in Australia, maybe you do need to sort of broaden your list of differentials a little bit more, but at least in Australia, if you've got big lymph nodes, both sides of the diaphragm in a dog, not just one lymph node or two lymph nodes.
Then I think, unfortunately lymphoma is definitely very much up the top of your differential list for your patient.Yeah.Both sides of diaphragm, meaning priest gaps, something new pillars and then pop the deals and things exactly, right.And back.
So it's not just like one mandibular and one priest Gap, but everything else is fine.It's, you've got them set of at the head end and at the tail end of the dog that you can feel externally cool, the infectious diseases, You say not in Australia.
We did an episode, I'll just put this in here in case anybody hasn't listened on Olivia and look here, look here.And one of the potential presenting signs is a generalized lymphadenopathy and that and that is it is in Australia now and yeah in the north and potentially coming down hitting down our way over time not quite lymphoma lymph nodes like halfway there so you're not getting these golf balls but they are.
It's a noticeable lymphadenopathy so maybe we're keeping that in the back of your head you know?Australia as well.Yeah, for sure.I'll jump in with a question that I contacted you about that day.Only because that's quite controversial.And even within the clinic, even after I spoke to you, and I made the decision to treat with breads.
I had a colleague, an experienced colleague.Say no, you can't do that.So, the question was dogs, think it's not eating?It's a Friday.Now, there's a whole weekend ahead.So I know nothing dramatic is going to happen over the next couple of days.I wanted to feel better but the owner was open to the idea of chemotherapy of The whole hog.
But I need to get this dog to eat and to feel better.And I know that breads are probably going to make her feel better in the short term.I contacted pain is to say, can I put it on parades and still refer and what was your answer penny?So the answer is there's no actually no agreed upon period of time that if you use prednisolone in a patient, you will induce resistance to chemotherapy because that's the concern.
People have been told and sure it does happen.You've Got a patient and it's been on cred the likelihood of chemotherapy working.Might be lower.That we don't actually know what period of time that is like, is it one day?Probably not.Is it one week maybe, but it seems unlikely.
Is it six months?Look, I think you're probably a bit more worried there.So there's no cut off point.And certainly, we might not ever find out what that is because it might be very patient specific.It might be one week in one patient, and it might be two months in another.I'm usually really Comfortable giving a suspected lymphoma patient prednisolone if we've collected enough samples from that patient and we're sure that those samples are going to be diagnostic.
So I think that's probably the biggest thing is lots of fine needle.Aspirates if you need to be collecting samples for something like flow, cytometry get all of that.Make sure that it's going to be diagnostic because one of the hardest parts about diagnosing lymphoma in the clinic on cytology is the Cells are super fragile.
They love to just crush and and you know, splutter all across your slide and then you get that comment back from the pathologist being like, this is non-diagnostic.So just make sure that when you're sampling, these patients, you are doing.It really gently, I never use suction.
When I'm efening these guys and spraying this out on the slide, really gently spreading it really gently but check it go and have a look under the microscope, you can usually tell are these cells intact.Have I smeared things, just right across the slide.
So as long as you've got enough diagnostic samples, and you're about to send them away.If your patient is sick, absolutely, you can give it steroids because like you just said here but that could be the difference between it making it through the weekend or not.And certainly if your patient is sick, prednisolone can be really helpful and really quickly getting them to feel better if though your patient is 100% well.
Comes in wagging, its tail owners, just found a lump and they're, like, all what's this?And not seeking any in any way.Maybe hold off.But if you're worried about your patient, and you think red is going to help this patient than absolutely, you can give it as long as you've got enough samples to send away.
I watch your dose of bread or jump in there.And they generated question, it's usually somewhere between one to one-and-a-half milligrams per kilogram.We're not trying to immuno compromised.These patients.It doesn't necessarily have to Be higher than that.I am a fan of giving an injection of something like dexamethasone first and then starting them on oral prayer.
Really, just depends how sick they are right.Like if they're sick enough to be in hospital, then giving them something IV or sub cut.Absolutely, you can if they're not eating sure.That might be the thing that gets them to start eating.Was that a total daily dose or a split?
The total daily dose, split in two on one in one day's, I don't mind okay, whatever whatever it is.Yeah.And you Dex dose would be something like point to milligrams per kilogram as a one-off.Yeah, sure.
And that a 24-hour thing for you decks or as a as a 12-hour or generally for me it's a 24-hour things.The question I had was about FNA is because I always wonder if I tried it a lot of samples, but is there like a number?You go for like and then so is it you sent away six slides or was that actually six aspirants and 12 slides?
And then what kind of needles do you use?And then when you say gently smear it, how do you gently Smith?Something?You put it down and it kind of sucks on to each other and it's like this lipid on attached to a rock that you're trying to pull apart.Yeah.
So I'll start with the needle size, I'll usually use a 23.The one of the light blue ones are usually attached that to a 5ml syringe just because I like the size of that but I'll pre fill that with some are.So when I'm actually taking the sample, I've got my needle already attached to my syringe.
It's already got air in it and I'm generally Lee trying to sample any big, palpable, lymph node, other than the mandibular is just because I know that we can get a lot of reactive sort of cells there because of how close it is to mouth and there's often pathology there so pre scapula and popliteal lymph nodes are probably my go-to source for sampling.
I'm not using any suction.I'm using sort of a gentle motion and quite often, you don't need to sedate these patients to do this.So, this is something that you can do like, Immediately after the consultation, when you've seen this dog with big lymph nodes, you can take it out the back and get the nurses to hold it and take some samples.
I will try and aspirate at least two different lymph nodes and do that node at least twice.So all up at least four different set of samples, but from each set of aspirin sample, you might be able to get two or three good slides.
The more the merrier definitely in terms of how do we not?Crush all these cells into Oblivion.I will gently aspirate with my prefilled syringe and then I'll lay my slides at a 90 degree angle.So instead of just straight over the top of each other, I'll put one sort of 90 degrees and then smear across you making across almost with your slides.
Yeah.Almost like a cross.Exactly.It is just a matter of not putting any downward pressure on that because like Dorado said, they do tend to stick together and then it's almost just a matter of trying to keep them as Parallel as possible and pulling them apart, no pressure down whatsoever.
In terms of, before I send this away, I'll usually pick one or two of the what looks like more cellular slides and you can usually see that you've got stuff on the slide even before you stain it.Right.And I usually pick one of the spreaders which maybe has a bit less material on it and one of the good slides and I'll difficult those and once you have diff quick, Get it.
You will also already you'll probably know before you even look at it under the microscope, they're purple like your your cells will come up a really deep purple or blue because there's a lot of nuclear material there.There's a lot of lymphocytes but all you need to be looking for is are these intact.
You don't need to be diagnosing lymphoma yourself, but you just need to make sure that you've got intact cells before you send that to the lab.So you said, you pick one slide and one of the spread Lives to the spread of slide.That's not unlike on a perpendicular that actually collects cells as well.
Some and yeah, usually, just right along the edge.Wow, that's what I normally do that because I don't want to waste my good slides, exactly myself, so that I just look to see how.Yeah I've got some sales and that's for any infant.A nice little.Yeah, it was so useful.That really was usually get I've ever made.
Yeah.I write myself as being pretty good at this and ironically this one even after you say to me, so any pennies response to me was pretty much all of this.And as always, I looked under the microscope and I mean yeah there was some ruptured sales but I could see some that looked like a myself was I got saying those off and I got a highly likely lymphoma diagnosis of that, but then they said, there's too much damage to do the special staining on it.
So why first of all, what talk about the special standing?I always in my head, you have to do biopsies then for further staining to differentiate tea from be.Yeah, so not anymore.We now have the ability to do, it's called immuno phenotyping.
So finding out whether it's be your booty, we now can do that on cytology and the reason that we need the cells to be intact is because we're actually looking at cell markers on the cell membrane, so not on the nucleus so you need to have whole cells in order to get this stain to stick.
Essentially, the Pathologists are going to be applying some stains that are sort of an antibody based Saying where they'll stick to certain receptors and not stick to others, we can do that now on cytology which is great because that means that if you get your cytology samples and they say even I've seen it a lot it says probable lymphoma or likely lymphoma as soon as you see the word lymphoma you know that pretty sure they can usually do that as an add-on test with the sample that they've already got.
And this is another reason why it's good to give them quite a few samples because they need a couple of extra slides in order to do this.Test because it's a different stain.The test can look quite spectacular.If you're actually getting the pictures of it, if they're all be went on the Beast and they'll come up as brown, if they're all T, they'll come up on the tea stain, as or brown, and then they'll be sort of almost like blank in the other.
So that's how you know, like, hey, this is a b-cell lymphoma or this is a T-cell lymphoma.Yes, you can still do it on histopathology.Absolutely.But the other test that we can use now in order to tell be versus T is something called flow.Saitama tree, which is kind of like the just the immuno cider chemistry, but next level because it gives us a whole variety of other markers that we can look at on those cells to.
So what do you need for that?Two things?So you can do flow cytometry on whole EDTA blood.So, that's useful when you've got a patient who you suspect has a leukemia, so they've got a really high circulating lymphocyte count or you.
Get one of those cbc's that cream of Pathologists and they've said there's a large population of other cells like they can't tell you whether they're lymphocytes or watch, so you can do flow cytometry just on whole EDTA blood, which is great, because it's just taking a blood sample from a patient.
But the other thing that you can do is, you can do flow cytometry on tissue samples.So that could be from F and as from a lymph node or multiple lymph nodes or the scenario that I most commonly used.In is finally last Spirits from a mass in the cranial mediastinum.
So we're trying to differentiate cranial mediastinal, lymphoma from a thymoma because on psychology alone, that can actually be really difficult and sometimes impossible, and your pathologist may not actually be able to do that for you.So flow cytometry for those samples can help you to differentiate all you're doing for that is the same as you would for an FN a but you are Sort of expelling cells onto a glass.
Slide, you're expelling cells into a solution of saline and serum to try and keep these cells alive in suspension to get them to the lab.If you want to do a test like this call and speak to your local lab because there is only a couple maybe one I could be wrong, there might be more now who do it in Australia and they do have some really clear submission guidelines because these cells have to be alive for the It's to be run.
So you've got to get the sample to the lab pretty quickly, but if that's something that you're pathologist has written, like, you know, we could do flow cytometry or they have the means to get it to the place that can definitely talk to them about.How exactly do you get them?Those samples.That's kind of cool because my, on the weekend, I diagnose my own Mother's dog with a 7.
By 8, cm modeled creating me to start on mass and it was kind of like it's lymphoma is that they Moma and it's like now we do core tissue biopsy next and stuff and I'm like, yeah, we're still consuming the whole process, but that's interesting to hear about the flow.
Cytometry Michael find out.Yeah, definitely have a chat.I'm pretty sure it will in New South Wales.I'll use fit gnostics.I would assume that any other lab that uses them should be able to do it for you.It is just a matter of getting the sample to the lab pretty quickly because you've got about a 24 or 48-hour window before these cells die.
Yes, sure.Just a quick Interruption.Yeah.I checked with the guys at Red gnostics, which is part of the SPs pathology Network that we mentioned at the start of this episode.So vet Beth ASAP laboratory and qml.That gnostics to fact-check beanie and they've confirmed that.Yes, they can indeed do all of these tests and yes the flow cytometry and aminu Saito, chemistry, that Penny mentions here are indeed exclusive test only available at their labs in Australia.
I will put some links in the show description as well as in the show notes that will take you to the sample.And guidelines and some additional information about the testing.If you want to dig into a little bit more, it's really quite interesting but it talks about how important it is to get these samples to the lab fast.Which is not a problem for I Australian listeners because the SVS pathology network has the largest network of careers.
In Australia, will make sure that your samples get back to them faster than you can assemble an equal it and put it on a boisterous, Labrador, pup without the help of your nest, okay?Back to Penny and you said, you want to collect that pre treatment as well.Yes, So when will you do that?
If you have a lymphoma case, You going to even a it at the first visit, as you say, that's an easy thing to do.You want to get all your samples?Do you, wait and see what the results say before you talk about flow?Cytometry?Oh yeah.Is it something you can jump to straight up for a dog that I suspect just has lymphoma, but certainly it is something that you could do instead of just submitting straight cytology and then getting the immuno side of chemistry done on top.
Absolutely.You could you could do that but it's not usually my go-to.To for diagnosing, just a normal lymphoma patient for a dog with a cranial mediastinal Mass.Yes, that will be the first test that I will do because you do also submit some cytology slides with it as well.
Hmm, what would be your white cell number that kind of gets you concerned that?There's a leukemia going on there like above 40 or something or supposed hands on the type of cell, if it's all it does.And it also depends on your patient because so the highwomen Highest ever circulating.
Lymphocyte count, I have seen in a patient was in a 10 year old Fox Terrier.That had gone into his vet for a dental and they did some pre anesthetic blood work.And here's and so he was completely fine.All you needed was teeth cleaned and here's circulating lymphocyte count with 750,000 the highest, everything was like, 130 or something, like The Buffy, coat must have been so big, so big, do they have?
Oh shit, clinically this patient was so well.So this came as such a shock to his owners to be like, hang on if you see even right.Like, let's just all let's just get an and it was, it was right?So that was a patient with chronic lymphocytic leukemia, which is definitely a more indolent type of leukemia where we do see really high cell counts and really well patients.
So like the the number And always correlate with how sick the patient is on the flip side of that.If you have a patient with an acute leukemia or you have a stage five lymphoma patient they're circulating lymphocyte count might only be something like 15 or 20 and they can be really really sick but those cells are going to be completely different type of lymphocyte to that dog that had the 750,000.
So those dogs with that really sort of a mile hike or mild lymphocytosis definitely flow.Cytometry could be very valuable for those patients to try and figure out.Hey a, we looking at something really terrible or is this actually something that is quite treatable and quite livable, but it's definitely worthwhile to sort of match that to your patient.
Sure.Yeah, I think the important thing to maybe bring up in regards to patients with lymphoma is prognosis in Adds to this stage.So when we have a cancer diagnosis for most things, you are going to be assigned a stage like, how bad is this?
How far has this gone?The difficulty with lymphoma though is because it's a cancer of white blood cells.It's a systemic disease usually.So even though we might only find it in specific anatomic sites, the assumption is that it can be everywhere and it often is Is, but at least within canine lymphoma, there are five stages.
So, you know, one through five, there's no prognostic difference between a dog with stage 3.And what stage 3 means is that you can feel peripheral lymph, nodes on both sides of the diaphragm are in large stage. 4 is, you've got evidence of liver and spleen involvement.
So, you might ultrasound a dog and see, like, all this looks, you know, mottled that he'll survive.Swiss cheese appearance of your spleen, or you might have a patient with some degree of liver dysfunction, and you look at their liver, and it looks really dark, and Nikki.And then Stage 5 means you're finding it outside of those normal.
Limb, like, limb for centers.So you're finding, it may be in the peripheral blood.So you've got a leukemia associated with that, or you're finding it in weird places, like the eye, or the CNS, or just somewhere else weird.But there's actually no, Curren in prognosis, for your patient who is classified as a stage.
Three verses your patient who is classified as a Stage 5.What is much more important is their substage?And substage is the, A, and B thing a is your, well, patient and sit there and be as you're a sick patient.
So, if you are a substage be patient, regardless of, whether you're a three or four or five, whatever your prognosis isn't going to be as good.If you're sick when you're diagnosed.So that's probably the more important part of it.So you can have a really well dog rock on in with big lymph nodes.
You take your CBC and you see all goodness.There's a lymphocytosis there, too.But the dogs fine that lymphocytosis and calling it a stage five isn't terrible news, and I think that can be hard for a lot of owners as well, just baffled because they hear stage five and they think, oh, God, it's all over.
Like, there's no hope.Which certainly isn't the case.So, the württemberg nose is for the ones that are sick.Is that, is there a difference in the type of cancer?Or is it just that they are halfway halfway dead and you have less time to get them back from it?
Yeah, so it may be that they're sort of more along in terms of progress.They've had this for longer but it just hasn't been noticeable.They're now starting to show systemic effects of that.The other thing I suppose that we can't always discount for is when we have a patient present to us, that is sick.
It does make it harder for us to Treat them.I know we've talked about chemotherapy before and you know the risk of side effects being low but it's not zero and it can be really hard for a patient who's already not eating vomiting has diarrhea like the risk that we have.
If we give them chemo yes we're treating their cancer to make them feel better, but we could also make them feel a lot worse.So there can be difficulties there when you have a sick lymphoma patient on, like what can we give you to try and make you feel better so that we can give you?
Chemo.And that's where pray right back to your initial question.That's where pride comes in because usually that does help.Cool, that's really useful.Actually, I made miss this, anything big difference between one and three, like, not a whole lot.
It's all got to do with one is like one lymph node.One side of the diaphragm to is more than one lymph node, but it's all on the same side of the diaphragm.Like, you might be mandibular, and Priests cap, and then three is both sides.Definitely your prognosis can be better if Classified as a stage one or two, but then, there's no difference between three to five.
Yeah.So, your gave that example, earlier of the dog has picked up on, pregel Bloods.What about other things on blood?So, if you're running Bloods, I know.Calcium is a common concern for cancers.Is that always the case how reliable is it?
And are there any other things that could give you clues that you should go looking for trouble?Yeah, so definitely hypercalcemia Is something that we do commonly associate with cancer?Yes.There can be a variety of other non cancerous lesion reasons.But in terms of the most common cancers associated with hypercalcemia lymphomas, probably the most common, but for dogs that are hypocalcemic, they are usually the dogs with T-cell lymphoma.
So if we look at lymphoma in general, you know, B versus T b-cell lymphoma is far more common in dogs about 70% of them, will have b-cell lymphoma, they NB hypocalcemic.But that doesn't happen often whereas the dogs who present with hypercalcemia and big lymph nodes.
They're much more likely to be T-cell.The other common cancer associated with hypercalcemia is Anal Sac adenocarcinoma.So if you have a hypocalcemic, patient, that doesn't have big lymph nodes.You definitely need to be doing a rectal exam which I suppose we all should be doing every time we see a patient anyway, but the hypocalcemic patients can be tricky.
Me too because they're often also the sick ones, they're the ones that come in with some degree of renal, dysfunction because of their hypercalcemia.So we need to be supporting them and treating them for that too.As well as hopefully treating the underlying disease which might end up being lymphoma Whenever not see when it comes to hypercalcemia ionized.
I'm talking about here because we have this, some blood Gas machine.I think the top bands, like 1.52 if it's 1.56, I'm like okay because my take is that it's pretty kind of strictly controlled.Yeah.And I've I've diagnosed dogs with the mediastinal masses and things and and double masses with hypercalcemia be like I'm a pretty boy like that's our not seeing him about.
The hypercalcemia news, is that overzealous?With the huh?The calcium your or is it is, I think so like it's, you know, it's it makes you look pretty good.Hey, when you've done a blood test on a dog and you've seen something like, now we need to do an x-ray of its chest because there will be a mess there.
And they're like, how do you even know that?But when you're right you're like yeah this is this is why I recommended doing those tests then I think any any patient that's hypocalcemic.We certainly need to try and figure out why.Because if it's cancer I will need to probably do.
Something about that.Hmm, don't know.Just just clarify.You said it sort of it as an afterthought that ionized calcium, why the difference between I know.So why do we reading for not on the blood, gas analysis?If we uh, normal in-house lab machine, what calcium is that checking for?
And why does that matter?I always find that it comes up earlier, shows up early, you be more sensitive with the ionized.So the times when I've picked it up really early or earlier, he is normal bike him.The total calcium is normal on the bike and but then the I know, Ty and that undoes the blood gas analysis and blood, Gas machine, check for ionized calcium, not total him, moist most blood gas machines, which to acid base and you know, blood gas analysis, will have ionized, but ionized won't be on your primary machine in house.
You have to send out.Look out how don't know what's your, what's your take on that Penny, ionized versus do by Kim calcium.Yeah, I definitely agree with you that if you're waiting for your patience total, Cesium to get high, you're going to be waiting a lot longer to see that.
So you may see some far more subtle elevations on an ionized calcium.The hard part is like how often are we going to are we going to be routinely doing that for all of our patients?Like maybe not because it is like an additional test like you said but certainly if you've got a total calcium that's high you definitely need to confirm that with an ionized calcium, but also your ionized calcium is probably going to be really high by that point.
Yeah yeah well while we dress the Basin blood, gas pedal stroke like everything was everything.Everything that comes in the door because they're sick.So we pick it up in much earlier and screening process but yeah, in general practice I wouldn't have done an ionized calcium at all and ever.Yeah, tell ya.
Wow, I've learned so much already.We do next.So any other bike and markers, or this calcium, the main thing, anything else that you should look out for?So on biochem you can also see some degree of Hepatic dysfunction as well.And certainly you can see that when you've got infiltration of lymphoma into the liver stage 4 lymphoma, patients have liver and spleen infiltration and sometimes you can have such a large degree of disease there that your liver isn't functioning properly.
So, you might see elevations in your alt, you might see changes to your bilirubin.And I think those two markers specifically are really important to me, but also everyone in town Save what chemo drugs are actually going to be safe to give this patient.
If you do end up diagnosing it with lymphoma because there are a lot of chemotherapy drugs that do need to be metabolized through the liver.And if you've got problems with biliary expression, for example, I'd be very hesitant to give that patient vincristine because we need that to be functioning properly in order to safely, give that drug.
So, I think those routine CBC biochemistry tests are really.Helpful to just check that everything still.Okay, but sometimes those results can influence.What drugs?We feel are going to be safe to give that patient in the initial stages of treating its disease.
Okay, that that begs the next question too.So let's say you've diagnosed or have a suspect or highly suspicious lymphoma case and you want to get an idea about how staging it so you want to obviously do if an ace of all the lymph nodes you going to do for biochem blood.
And ultrasound to look at liver and spleen and see what's happening.Internally reading, chest stretch as well or what includes your full workup for these guys.So you definitely can be doing all those things like, you definitely can be doing ultrasounds and chest radiographs.
And I feel like for those dogs that are hypocalcemic, you're probably going to do a chest radiograph to look and see what's going on in the cranial mediastinum.Is there a mass there?Is there not, but kind of going back to what I said before.Before there's no real prognostic difference for your patient, whether you do find that or whether you don't, okay?
So although it is really nice to have chest radiographs abdominal ultrasound as part of your staging.And definitely, that is what we would deem is being complete staging.Because the other thing is you might find other things, you might find other abnormalities not related to the lymphoma.
You don't actually have to do those things because it's not necessarily going to Change.How you treat the patient or what their prognosis is.So when I have patients referred to see me, who have been diagnosed with lymphoma based off an F an A, or a biopsy or anything like that, I will talk to people about, you know?
Yes, we can do these tests to get more information but we treat this as a systemic disease, we assume this could be and often is everywhere, okay?And if it's not going to change our prognosis and if it's not going to change how we treat, like what drugs we pick and stuff like that, then we don't have to do those tests.
Okay?T vs be you know, which is the better one, you know, if I was going to pick one, which one would I want?If you had to pick if you're a dolt if you had to pick a type of lymphoma and let's just be clear.
This is for our typical.Multicentric intermediate to Large Size because that's the most common diagnosis that we get, like, high grade or large cell multicentric lymph node lymphoma in a dove.You've probably won't be there.
Was that sort of saying, be, as bad, and T is terrible.I do treat them differently.So, I will use different drugs for a dog that has T-cell Lymphoma versus a dog that has be.So lymphoma and that's fine.
There are also oncologists who do not do that.There are also in colleges who treat them all with the same drugs fine.It's also as much as an art as it is a science sometimes.So b-cell lymphoma is the more common about seventy percent of dogs will be diagnosed with lymphoma will end up having be, it is seen as the better type of lymphoma to have, and that comes from Um the idea that treated with multi-agent chemotherapy average remission times are around 12 months, we recognize that averages mean that 50% can do better than that and fifty percent don't do as well, but about 90% of dogs who are diagnosed with b-cell lymphoma will go into remission which is a really high rate.
T-cell.Lymphoma we say that in just under 30% of dogs with multicentric lymphoma quite commonly.They are dogs that are sicker when they're diagnosed and that may be because of the hypercalcemia it may be because they've got a cranial mediastinal Mass.
That's effusive.Like there are a number of reasons why that could be the case we see still quite High remission rate.So like 80 to 90 percent chance of going into remission with chemotherapy but But the remission times are not usually as long, so I treat them differently, different drugs, I will quote people, 90% chance of remission, and on average, that would be about 10 months.
So it's not dramatically worse, it's not dramatically worse with in both B and T.So we recognize that about 20 to 25 percent of patients, will still be alive at two years.So you've got, let's say a one in four chance of still being here at to Is if you're treated with multi-agent chemotherapy and that's that's T Cell as well.
Yes.Okay.All right.So it's not such a big difference, really nice makes me reconsider my mom's dog.She's like, you know, I don't really know if I want to do this.You could be a slave in your differentiate between timer and Lymphoma but then like he's got a numbers, you know, kind of make me think, you know, who might be worth a go.
The other thing I suppose is it is important to know.Between the two of them because if I Moma is a surgical or a radiation disease and you can be fixed with that.Like, if you can cut it out, you can be done, which is great.
So moment doesn't respond to chemotherapy really much at all.Whereas lymphoma is absolutely not a disease, I would be recommending surgery for that.No, that would be terrible but certainly could respond to radiation to.But before you go down the path of RP kind of want to know what a trading.
But yeah, like even if it is T-cell lymphoma, you've got a pretty high chance of responding positively to chemotherapy going into remission and still being around for, you know, tap averages 10 months, but there's a one in four chance of two years, which is pretty good.
I think that's it.Is there anything we missing?But we recovered it.I feel like I've learned a hell of a lot of a random question about Anal, Sac carcinomas.It's like a bit like a, like they should be big or is like, okay my God.
This this anal gland is like the size of a pea.Yeah, this is that abnormal.I can't express it to size of a pea, the other one I express and it's empty.Like, is that enough?Yeah.For sure, the problem with Anal Sac tumors is that you can have a really tiny primary tumor and horrible metastatic disease.
Whereas, you could have a really big, you know, like tennis ball.Humor and find that it hadn't spread, but also that tiny tiny 5, mm, pea sized tumor could absolutely be enough to make your patient hypocalcemic.So, I think that if ever you find an abnormality when you're doing a rectal on a dog or expressing anal glands and it just doesn't feel right.
I'd be flagging that for follow-up and you know it is possible to FNA them fairly simply, you will often get a cytology result back that will say.Something on the lines of epithelial me a pleasure and on cytology these don't look that aggressive but we know that they absolutely can be.
Yeah that's all of it.I will just add one more thing.Again goes back to this one case and that's something I've learned since chatting to you Penny.It's just the approach to it.So that case I saw this at thirteen year old Goldie.Yeah.It's all we had started having these conversations in in an emergency clinic as I was To me, that would have been, you know, I'd assume that and it's not gonna go any further with this.
Then it's maybe talk about palliative care.And then, let's talk about euthanasia.Hmm.And then after your conversation of your perspective, that sometimes people are happy with an extra three months, or how extra year or so.And I gathered as a consultation went on, this was a really, really valued pit.
They had kids but this was the first born and was a bit and sometimes this makes a difference but it was a middle-aged man.Man sort of my age which again, I assume that it's a no.Let me go.That's the team's got cancer.No ways.
But I stopped my first instinct and I said, these are the options.This is this chemo and that can extend life and give greater good quality of life, just the stuff and she said he'd been teaching at and he considered it.I think in the end he did euthanize it after a week or so I think she didn't really do much better on the braids and I think they made peace with it.
But just me not jumping to that decision for him.Because previously, I think I would have managed to easily push him into euthanasia because of, in my head that would have been the right thing.But, no, it was just just keeping the door open and saying, these are all the options and not just jumping to.
It's just, you know, there's no ways really helped and I was, I was pleasantly surprised.He went to Kelly, I'll go home and talk to my wife and think about it.We'd love to have her around a little bit longer if we can.So I think it's really, really an invaluable thing.Yeah, I think even just for some people going away and thinking about it, even for a day or two can be really helpful because maybe you know like they probably turned up to the emergency clinic.
Not thinking that was good.He was shocked.He's you're gonna get like I said I try to stole telling you what I found.I literally went to cuddle the dog and I went off.Yeah.And I didn't want to tell him so I did my full exam.I did and I went well, my major concern is this big and friends, which normally Soon, as I can sir, he's is years.
Just started watering his eyes started watching.He got all Terriers are gone now.I've broken his heart, but it was nice to be able to give that other option.It really is.I think the only other thing that I just wanted to talk about and it's applicable for dogs and four cats.
But it's got to do with pathology and what like the information that your pathologist can give you that is going to be really helpful to you, to be able to talk to Is about, is this a good type of lymphoma?Or is this a bad type of lymphoma?
And what I mean by that is essentially Under the Umbrella of lymphoma the first to sit of big categories, are large intermediate, or large cell, which in dogs is the most common type that we see or there is small cell lymphoma.
And small cell lymphoma is very much like what we see in a lot of cats with like low grade elementary level, Coma.And it's got to do purely with the size of these cells.Small cell lymphoma does happen in dogs too.And for a dog, who's diagnosed with small cell lymphoma, that could be in the gastrointestinal tract that could be in the spleen that could be in a lymph node.
If those lymphocytes are described as being small by your pathologist then this may actually be a far more indolent and less aggressive disease than when those lymphocytes are described as being.Intermediate 2 large and I think it goes the same for in cats as well.
If your pathologist is saying, this is small cell lymphoma that's generally a good sign and they can do a lot better than an animal that ends up being diagnosed with large cell lymphoma.So just when you get those pathology reports and you see immediately scanned down to the thing that says diagnosis and it says lymphoma, just make sure that you go back into that description to see like what the pathologist said about this.
The size because that may be really helpful to you to have a conversation with your owners from there, even before you've done B versus T and all that kind of stuff.It's tough did not know that.All right.Great.Oh, actually well any difference between like pred only like what surprise your Ambitions.
Yeah.Oh yeah definitely.So if we have clients and a patient who have decided that chemotherapy is not something that they feel is appropriate or that they are able.You do for their pet which is fine.The minimum that I would be doing is putting this patient on prednisolone.
We know that it can has an anti-cancer effect so it can shrink lymph nodes, not all the way down to remission.But by quite a lot, in some patients, which is great.But it can also have some really nice side effects which we love.
So it does act as a little bit of an anti-nausea medication increased.Their appetite increases their drinking generally just makes them feel a bit.It better, but for animals, or some former that's usually only for a relatively short period of time.So average period of time that they're feeling good.
Just on palliative prednisolone is somewhere between 6 to 12 weeks, definitely.I've had patients who have done a lot better than that and that's always wonderful.But yeah, 6 to 12 weeks is definitely the average and then you start to see the lymph nodes.Will start to get big again, they'll start to feel unwell.
And at that point, they will probably be put to sleep.Awesome.Never that.Yeah, the strap that out.That's great.Thanks again for any so informative.For you right away.We have a few more tickets left for our live event on 22 to 25 November in Noosa which is getting really close.
So jump on it.We finalized the clinical program for the to clinical days with Professor, Joe medicine, and prof.David church and it's a little bit epic.We talking to Prophet Joel about better clinical reasoning and we doing clinical conundrums, which are case studies that will use to build on the content that she teaches and prove David of course is covering everything in a chronology from the highs.
And Close of cortisol to better ways of thinking about and managing your tricky diabetics.But it's not just going to be lectures.We doing questions and cases and discussions and of course some podcasting come just for the to clinical days will come for the full four day event and all of the associated advantages in the best location in Australia.
The link for the event is in the show description and remember to use VV listener all caps at checkout for a 300 dollar discount on your tickets.Hope to see you then.Okay.Bye.Close of cortisol to better ways of thinking about and managing your tricky diabetics.But it's not just going to be lectures.We doing questions and cases and discussions and of course some podcasting come just for the to clinical days will come for the full four day event and all of the associated advantages in the best location in Australia.The link for the event is in the show description and remember to use VV listener all caps at checkout for a 300 dollar discount on your tickets.Hope to see you then.Okay.Bye.

Dr

Dr Penny Thomas