Now Phoebe has Lymphoma

[Laurie and Tasha]

I suppose this is what I get for having a geriatric household. . . .

Phoebe was urinating seemingly hourly, and sometimes more frequently.
as well as losing weight. Took her into the vet for a checkup, did xrays and bloodwork. Doc brought xrays into the room, and said, "I see why your cat is using the box so much!" She had two pea sized bladder stones and a tiny kidney stone as well. She urinated on the treatment table, and he collected it for a urinalysis. No need to look for blood, though. It was almost pure red. He said the only other somewhat remarkable thing he saw on her xrays was her intestines looked more gassy than he would like. Put her on Clavamox and said we would remove the stones when the UTI cleared up. This took about a week.

We had the surgery and doc said he did a biopsy of her intestines, even though they "didn't look that bad". Sent us home with Zenoquin and we waited for the biopsy results. Couple of days later the doc called and said biopsy came back as lymphoma. He said he was really surprised by this diagnosis - wasn't expecting it. Maybe we are kind of lucky and caught it early, so she won't be as sick as fast as Tasha was.

Right now, we are giving her Prednisolone 5 mg BID for a week, and then once a day for a month. We'll see if she gains some weight (now 7.5 lbs - down from 9) and take it from there.

While Kira and Phoebe were not littermates, I did get them on the same day from the shelter 7 - 5 - 1996. It has been so sad losing Kira so suddenly, and now this. Oh well.

[Traci]

Aw, geez, Laurie, I'm so sorry to hear this. Are they certain? Did you read the pathologist's report?

Maybe more importantly, have you consulted with a feline oncologist?

[Auntie Debbie]

I'm so sorry Laurie about Phoebe. Are they absolutely sure? I agree with Traci on seeing an oncologist for this.
She's in my prayers for a recovery or misdiagnosis!!!!

[Tina B and crew]

Sorry to hear about Phoebe...I will keep her in my prayers.

[Laurie and Tasha]

I am so sorry it has taken me so long to get back to you on this... here is Phoebe's pathology report:

Two sections of jejunum are similar. In each there is a moderate to severe villus blunting and fusion. Throughout the lamina propria there is a diffuse infiltrate of small well-differentiated neoplastic lymphocytes. Neoplastic cells infiltrate a few of the villus and crypt epithelial cells (epitheliotropism) and also extend down into the submocosa.

Diagnosis: Jejunum: small cell lymphoma

Comment: A guarded prognosis is given. Lymphoma can be focal, multifocal or diffuse in the intestines. It can also involve regional lymph nodes, liver, and spleen.


Okay, so my vet told me that during surgery, he checked Phoebe's liver and spleen, and they looked clean. He also said he has recently attended some continuing education seminars where he learned that it is becoming clear that it is sometimes difficult to differentiate between GI lymphoma and IBD on biopsies. He said the treatment is basically the same for both.

I have a question about the commented prognosis - guarded for what period of time, I wonder. It leaves that question open.

Clinically, Phoebe is doing quite well on the prednisolone. She has gained weight and is acting normally - eating, drinking, no diarrhea.

Haven't gone to an oncologist yet, the closest one is in Akron, and I am not really sure what he could tell me that would be enlightening to her condition.

I wish there was an objective way to monitor the progression of this without doing another biopsy.

[Traci]

Laurie,

The thing about pathology reports is that they don't always mean conclusive. There are various types of tests, stains used, etc that can be done to come to some sort of conclusion. For example, special stain tests can be done on some types of samples that give the pathologist a better idea of the type, treatment options or suspected progression. Sometimes one test is not enough, or the sample isn't enough, or there are numerous variables to consider.

While a vet should never ever assume that just because surgical margins "appear" clean, the biopsy is necessary, because a vet can't see cell structure and other variables that make up the supposed nature of the tumor (or metastisis has occured elsewhere the vet hasn't checked). And sometimes, a pathology report isn't always conclusive, but rather, assumed or predicted based on the sample tested or experience of the pathologist.

"guarded" in prognosis generally means to predict a tumor will be unresponsive to available treatment. But, that isn't 100% conclusive because it is possible the diagnosis is wrong, or the patient may well indeed respond to treatment (the most common being multi-approach, like surgery and then chemotherapy, or surgery and then radiation treatment, or pallative care such as use of prednisone and other symptomatic care that doesn't include chemo or radiation)

Your vet is correct that diagnosis can be confused with another condition, it happens all the time, but this is when you get into a grey area and try to decide if another biopsy, with additional testing done at the time of pathology/histiology or with another pathologist. The samples are crucial, meaning the samples should contain the areas most suspected of the cells or involved tissues etc. in order for the pathologist to determine cell structure, metastisis if present, prediction of response to treatment.

There are laparoscopy procedures available now that are a bit less invasive than exploratory open surgery, your vet should consult with a feline specialist or onclogist for options, or better yet, consult with a feline oncologist about the pathology report so that he can get advice and direction on how to proceed or whether to proceed further. He should have offered that option to you once he reviewed the pathology report. He can also consult the pathologist for comments on whether or not the first sample was adequate, or would have been beneficial to test further, etc.

If you're not comfortable with your vet at this point, or his experience level, have you considered seeking a second opinion? If so, go directly to a feline oncologist, but first review this with your own vet, he should be able to consult on your behalf or refer you for a consult. You do not have to proceed with another biopsy, but it would be helpful to at least get the opinion of a feline oncologist and to have the oncologist review Phoebe's pathology report as well as all her current medical records (including bloodwork and xrays, ultrasound results etc).

Hang in there, you and Phoebe have remained in my thoughts and prayers, please do talk to your vet further and request a consult on your behalf.

[Laurie and Tasha]

Traci,

Thanks as always for your invaluable insight! I was wondering if you thought her severe bladder infection and stones could have irritated her bowels to the point that abnormal cells would appear. This was a really, really bad infection.

There are eight vets on staff at my clinic now, a new one is board certified in canine and feline internal medicine, and most of them have tons of experience. I have complete confidence in them. Having worked there for 18 months solidified my trust. I hope I can go back there some day to work, too!

If there are lymphoma cells in the jejunum, would they appear in the duodenum, also? I thought maybe we could do another biopsy via endoscope. It just seems so subjective to wait and see if she starts losing weight again, or develops diarrhea. I guess no needle biopsies of the intestines? Unfortunately, my clinic does not do laparoscopies yet.

You mentioned surgery as part of a treatment plan. If the lymphoma is diffuse throughout the intestine, what type of surgery could be done?

Do you know anything about PET scans to detect cancer cells in animals?

[Traci]

The first question you'd have to ask your vet, I'm not sure if the cells would affect both, because they kind of have a weird structure.

I doubt the infection and stones had anything to do with creation of these type of cells.

Needle biopsies wouldn't be exactly possible without knowing the location of the suspect area, because the intestine is rather bunched and coiled. An endoscopy might be possible to get a tissue sample for testing, but it might be the wrong area suspected. Your vet can tell you more about an endoscopy procedure. Endoscopies are used however, to confirm IBD in some cats, or when there is a suspected mass/obstruction that relates to IBD.

When I mentioned surgery, as part of the treatment, I mean removing masses, suspect tissue, or even partial removal of part of the intestine, then followed by chemo or radiation therapy. Depending on the cell structure, rate of metastisis (if any), type of cells, would depend on the prediction of response to treatment (i.e., from a pathology report). Unfortunately, this often requires open surgery (exploratory or open abdominal surgery). This is why it might be beneficial to ask your vet about laparoscopy and if it's possible to go that route, if it ever came to that. Laparoscopy would only involve a small section, surgically, as opposed to open abdominal surgery. It would still require expertise by a qualified surgeon and proper followup care.

I think if lymphoma were diffuse in the intestine, you'd be seeing a host of symptoms and illness, progressive signs (unless it wasn't detected early and it could be in mid to late stage disease). Unfortunately, if it were diffuse or rapidly spreading, surgery would probably not be helpful.

I'm not sure if a PET scan can detect such cells, but it might detect metastisis or rate of metastisis (if any) and location most affected.

I still encourage you have your vet consult with a board-certified feline oncologist, not meaning you'd necessarily opt for chemo etc, but to get an opinion on the pathology report, and even see if this were misdiagnosed, or for treatment options.

[Laurie and Tasha]

Took Phoebe to the clinic today for a weight check, and she is up to 9 lbs!!
This is up from 7 lbs 13 oz 6 weeks ago. We have changed her prednisolone from every other day to every third day, and will check her weight again in 4 to 6 weeks.. Yippee!

[Traci]

Wonderful news! Hopefully, the diagnosis on the part of the pathologist is wrong!

Were you able to spend some time with the vet for discussion?