Lymphoma by Veronika Langova. Veterinary consultancy content from SASH.

1. Personalized lymphoma treatment
Small Animal Specialist Hospital
Dr Veronika Langova & Dr Sophia Tzannes

2. Personalized lymphoma treatment
• LSA is the most common hematolymphatic
neoplasm accounting for 5 % of all canine
malignancies
• Annual incidence 1/4000 dogs
• Most dogs present w generalized
lymphadenomegaly
• Most dogs have high grade LSA w small proportion
of having low grade or indolent form

3. Personalized lymphoma treatment
• Aim of this talk is to alert you to the less
commonly seen types of LSA which require
recognition and appropriate management
• Questions:
• How do we diagnose them?
• What is the clinical relevance?

4. Personalized lymphoma treatment
• Treatment of hematopoetic neoplasia requires
a specific, rather than general diagnosis that is
based on cell architecture, cell morphology,
phenotype and genetic rearrangement

5. Lymphoma classificationLymphoma classification
• Changes in our understanding of lymphoid
neoplasms have resulted in the evolution of
numerous clinical and pathologic classification
schemes over the past 50 years.
• In 1994, the Revised European-American
Lymphoma (REAL) classification was proposed
which incorporated morphologic,
immunophenotypic, genotypic and clinical
features into disease subtype definitions.

6. Lymphoma classificationLymphoma classification
• In 2001, the World Health Organization (WHO)
introduced a new classification built on the
REAL classification that represents the current
“gold standard” for classifying all human
hematopoietic neoplasm’s.
• This classification provides system ofThis classification provides system of
categorizing lymphoid neoplasm according tocategorizing lymphoid neoplasm according to
their level of cellular maturation that alsotheir level of cellular maturation that also
provides a level of prognostic indicationprovides a level of prognostic indication

7. Classifying canine lymphomasClassifying canine lymphomas
• Valli et al produced a paper in 2010 which looked at the accuracy and
consistency of veterinary pathologists in applying the WHO system of
classification to canine lymphomas. This study found that veterinary
pathologists could achieve a high degree of accuracy in applying the WHO
classification system to canine lymphomas.
• Since only follicular lymphoma can be accurately diagnosed on H&E
staining and that subtype is uncommon, immunophenotyping is essential
for an accurate diagnosis of canine lymphoma.
• All cases were phenotyped w CD3/CD79, if histiocytic proliferation was
present then CD18 was tested
• Clonality was verified with PCRClonality was verified with PCR
• Genetic rearrangement was evaluatedGenetic rearrangement was evaluated

8. Classifying canine lymphomasClassifying canine lymphomas• Summary of Canine Malignant Lymphoma Revised From the Revised European-American Classification of
Lymphoid Neoplasms/ World Health Organization Classification of Lymphoid Neoplasms
B Cell Neoplasms
Precursor B cell neoplasms
Precursor B lymphoblastic leukemia/lymphoma
Mature (peripheral) B cell neoplasms
B cell chronic lymphocytic leukemia/prolymphocytic
Leukemia/small lymphocytic lymphoma
B cell prolymphocytic leukemia
Lymphoplasmacytic lymphoma
Splenic marginal zone B cell lymphoma
Plasma cell myeloma/plasmacytoma
Extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue type
Nodal marginal zone lymphoma
Follicular lymphoma
Mantle cell lymphoma
Diffuse large B cell lymphomaa
Mediastinal large B cell lymphoma
Burkitt’s lymphoma/Burkitt’s cell leukemia
Provisional entity: high-grade B cell lymphoma
Burkitt’s-likea
Primary effusion lymphoma
T Cell and Putative Natural Killer Cell Neoplasms
Precursor T cell neoplasm
Precursor T lymphoblastic
Lymphoma/leukemia
Mature (peripheral) T cell and natural killer cell neoplasms
T cell prolymphocytic leukemia
Large granular lymphocyte leukemia (LGL)
Aggressive natural killer (NK) cell leukemia
Peripheral T cell lymphomas, unspecifieda
Adult T cell lymphoma/leukemia
Intestinal T cell lymphoma (+enteropathy associated)
Hepatosplenic gdT cell lymphoma
Subcutaneous panniculitis-like T cell lymphoma
Mycosis fungoides/Sezary syndrome
Anaplastic large cell lymphoma, T and null cell primary cutaneous
type
Peripheral T cell lymphoma not otherwise specified
Angioimmunoblastic T cell lymphoma
Angiocentric T cell lymphoma
a Peripheral T cell lymphomas are those that are not otherwise specified
(NOS) to a specific subtype by further definition

9. • 7 diagnostic categories then divided into 3 major groups ;
– high, intermediate, low
• Most common LSA centroblastic large B cell
• Longest survival low-grade T cell (T-zone ) 622 days
• Shortest survival T cell high grade (peripheral T cell) 162 days
• high grade LSAs –unwell
•
• indolent low grade –free of CS
ValliValli et alet al

10. • LSA is generally extremely sensitive to chemotherapy w CR 65-90% MST 26-51 W
• Variety of chemo protocols are used and general consensus is that Doxorubicin –
containing protocols are associated with the longest DFI and OS
• Does specific diagnosis of LSA subtype have a similar impact on ST in dogs as it did in
humans and did specific diagnosis in a dog impelled the specific chemotherapy required?
• Effect of Tx chemotherapy for high grade B and T cell LSA inc ST
• Contrary chemotherapy for T zone LSA decreased ST ( 13 dogs no Tx longest ST 687D0
•
ValliValli et alet al

11. ImmunophenotypingImmunophenotyping
• Immunohistochemistry and
immunocytochemistry refer to the process of
detecting antigens in tissues or cells by
exploiting the antigen-antibody binding
process found in biological tissues.

12. ImmunophenotypingImmunophenotyping
• The diversity of immunophenotyping markers used
in diagnostic pathology is substantial and more
markers are becoming available in the veterinary
field. Some examples of commonly used markers
include:
– CD3: T cell lymphoma
– CD79a: B cell lymphoma
– CD18, 11: Histiocytic disease
– CD117: KIT used to identify MCT’s and GIST’s
– Vimentin: a marker common to sarcomas

13. ImmunophenotypingImmunophenotyping
• Histologic and immunohistochemical review of splenic
fibrohistiocytic nodules (SFHN) in dogs Moore 2012
– Splenic FHN cases were re-evaluated in 32 dogs
– Histo Grade I(2) Grade II (9) Grade III(21) dogs
– CD3,CD20,CD79a,CD18,CD11d, K1-67 used to reclassify
– Grade I- MZL and lymphoid nodular hyperplasia
– Grade II-MZ hyperplasia(1), MZL (1), complex hyperplasia (2), LNH(1), stromal
sarcoma (3)
– Grade III- MZH(1), diffuse large B cell LSA(1), MZL(1)CNH (6),LNH (1), SS (5), HS
(6)
– Prognosis HS- poor 74 days
• stromal sarcoma 488 days, 565 alive 1 year
• 8 dogs with CNH MST 387 D 70% alive 1 year
• 5 dogs with LNH MST 570 D 60% alive 2 years post splenectomy

14. PARR and FlowPARR and Flow• What is the difference between flow cytometry and PARR?
• The PARR assay is a PCR assay in which we are amplifying DNA to
evaluate lymphocyte (LCT) receptor gene length. In a heterogenous
LCT population the LCT’s are all genetically distinct so the LCT
receptor genes vary in length.
• Homogenous or clonal LCT population, is often malignant and have
identical gene length throughout the population.
•
• The results tell us if the majority of cells in
the sample are derived from the same
original clone (most consistent with
neoplasia), or from multiple clones (most
consistent with a reactive process-
inflammation, immune mediated dz or
infection)

15. PARR and FlowPARR and Flow
• What is the difference between flow cytometry and PARR?
• Flow cytometry (FC) allows identification and quantitation of cell
surface markers
• The FC study involves staining live cells (blood, BM, LCT) with labelled
antibodies that bind to proteins expressed on the cell surface
• The cells are analyzed on a flow cytometer, which tells us how many cells of each
type are present. This information allows us to determine the lineage of the cells
present, and whether they are homogeneous (more consistent with neoplasia) or
heterogeneous (more consistent with a reactive process
• Limitation – sample collection- EDTA, 24 hours not frozenLimitation – sample collection- EDTA, 24 hours not frozen

16. Ben 10yr MN JRT
• Presented November 2012 with
haemabdomen
• Splenectomy was performed
•

17. HISTOPATHOLOGY REPORT
An 80mm coarsely multinodular portion of dark semi-firm tissue. On section, the cut
surface presents multiple 1- 3mm diameter multifocal coalescing pale foci, sometimes
with central congestion or haemorrhage. Multiple representative sections (A-J) are
taken.
GROSS PATHOLOGY
The pale foci evident on macroscopic examination correspond to irregular coalescing
multinodular aggregations of marginal zone-type monocytoid lymphocytes. The
aggregations are centred on the arteriolar structure of the spleen. The monocytoid
lymphocytes infiltrate the walls of blood vessels and there is subendothelial colonisation
by neoplastic cells. The mitotic index approximates 2 mitoses per 10 high-power
fields. Residual splenic tissue is congested and has infiltration by haemopoietic cells.
DIAGNOSIS:
Lymphoma
COMMENTS:
This is a low to moderate grade large-cell type of lymphoma originating probably from
follicular marginal zone lymphocytes (MZL). Marginal zone lymphomas are usually
indolent.
Ben 10yr MN JRT

18. Indolent lymphoma in humansIndolent lymphoma in humans
• If detected early and only involving one or two lymph nodes,
radiation is often recommended and this can result in a cure or long-
term remission.
• A ‘watch and wait’ approach is commonly undertaken patients are
asymptomatic
• Traditionally fairly chemo- RT resistant- conservative Tx
recommended
• The clinical course is extremely variable, with some patients having
an extremely aggressive course and death within 1 year, whereas
others may live for more than 20 years and never require therapy.
• Disease transformation to a more aggressive histologic type is a
common terminal event
• Most patients are >60yrs of age and present in an advanced state of
disease with >50% having bone marrow involvement

19. Indolent lymphoma in dogsIndolent lymphoma in dogs
• Indolent lymphoma comprises 5- 29% of all canine
lymphomas
• Limited information regarding the subtypes and
biological behavior.
• Canine indolent lymphoma consists of a group of
diseases that are histopathologically similar to subtypes
of non-Hodgkin’s lymphoma identified in people.
• Histopathological subtypes:
• B cell- marginal zone (MZL), follicular
lymphoma
• (FL) and mantle cell lymphoma (MCL ),
• T-zone lymphoma (TZL).

20. 20
Germinal centre of follicle
Marginal zone
Lighter
Trabeculae
Capsule
Mantle zone
Darker

21. Indolent lymphomaIndolent lymphoma
• B cell predominant
• Both B and T cell indolent lymphomas share a
low mitotic rate, slow rate of progression
• TZL can be difficult to recognize as malignancy
given the small mature –appearing cell type
and low mitotic activity.
• Detection of clonality is useful adjunct to
histologic examination

22. Indolent lymphomaIndolent lymphoma
• Splenic marginal zone lymphoma in 5 dogs - Stefanello et
al 2011
• small study, retrospective
• Hallmark of splenic MZL was focal hypoechoic mass, which became
symptomatic only if ruptured.
• Unlike in Hu BM involvement is rare 0/5
• ST- 760,939, 1825 days, one alive 445 days, one died 180 days.

23. Indolent lymphomaIndolent lymphoma
• Clinical characteristics and outcome in dogs with
splenic Marginal Zone LSA O’Brien JVIM 2013
• 34 dogs retrospective study
• MZL – nodal, splenic, mucosa associated
• Little known about clinical outcome
• CS - 15/29 attributed to splenic MZL - hemoabdomen, distended abdo,
lethargy, anorexia + weight loss
• Only 1 dog with disseminated dz, rest were splenic only
• Pre-sx dx - FNA of spleen 13/29 dogs, + result in only 3, 10 - extramedullary
hematopoiesis, hyperplasia, reactive, inconclusive

24. Indolent lymphomaIndolent lymphoma
• Clinical characteristics and outcome in dogs with splenic
Marginal Zone LSA O’Brien JVIM 2013
• Good outcome after splenectomy overall MST 383D, 571 days with
exclusion of perioperative deaths.
• Only 5 dogs did not have any other concurrent disease - MST 1001dOnly 5 dogs did not have any other concurrent disease - MST 1001d
• Only PF was diagnosing MZL as incidental finding
• Chemotherapy may not increase ST= human counterpart, chemo
used only if splenectomy is contraindicated.
• Chemotherapy can select for more aggressive behavior in indolent
LSA

25. So how is Ben?
•

26. Piper Rossano 11yr FS
Labrador
• Presented with pancytopaenia and
• splenomegaly.
• No peripheral lymphadenopathy
• Ultrasound guided splenic FNA
• The liver was aspirated and bone
marrow collected.

27. Piper Rossano 11yr FS Lab
• HAEMATOLOGY
• Test Result Alert Units Reference
Range
• *RBC 3.2 Low x10^12/L 4.9 - 8.2
• *HAEMOGLOBIN 66 Low g/L 100 -
206
• *HAEMATOCRIT 0.20 Low L/L
0.35 - 0.58
• *RETICULOCYTE % 3.8 High % 0.0 -
1.5
• *RETICULOCYTE ABS 122 High x10^9/L
10 - 110
• *MCV 63 Low fL 64 - 76
• *MCH 21 pg 21 - 26
• *MCHC 330 g/L 310 - 360
• *PLATELETS Decreased
• *PLATELET COUNT 63 Low
x10^9/L 200 - 500
• *WBC 3.5 Low x10^9/L 4.5 - 17.0
• *NEUTROPHILS% 74 %
• *NEUTROPHILS 2.6 Low
x10^9/L 3.5 - 12.0
• *LYMPHOCYTES% 9 %
*EOSINOPHILS 0.0 x10^9/L
0.0 - 1.4
*BASOPHILS% 0 %
*BASOPHILS 0.0 x10^9/L
*PROTEIN PLASMA 56 Low g/L
62 - 85
*PLASMA APPEARANCE Normal
*BLOOD SMEAR EXAMINATION
Moderate anisocytosis Mild
macrocytosis White cell morphology
normal.

28. Piper Rossano 11yr FS
Labrador• SPLENIC ASPIRATE; Four routinely stained slides
• DESCRIPTION: Four slides of high cellularity and excellent quality are examined. Slides contain many neoplastic round cells
and few haematopoietic progenitors present both within and between moderate numbers of splenic stromal fragments and
abundant blood.
• Neoplastic round cells are large (15-25um in diameter), moderately pleomorphic, present individualised, and discrete. Nuclei
are round to rarely reniform in shape and eccentrically located with finely granular chromatin containing 1-4, often prominent,
nucleoli. Cytoplasm is scant to moderate in amount, deeply basophilic, often vacuolated, and occasionally contains
erythrocytes. Mitoses are occasionally noted. Pleomorphism is characterised by moderate anisocytosis, moderate
anisokaryosis, multiple nucleoli, and occasional reniform nuclear shapes.
• Haematopoeitic progenitors are most often erythroid with few myeloid and rare megakaryocytes. No microorganisms are noted.
• INTERPRETATION: Malignant round cell neoplasia; Probable lymphoproliferative disease (see comment)
• COMMENTS: The predominant cellular population is the neoplastic round cells. These are most cytologically compatible with
lymphoid cells and as such large cell/anaplastic lymphoma or acute lymphoid leukaemia (ALL) are the most likely
differentials. Acute lymphoid leukaemia must be considered given the pancytopenia although no circulating neoplastic cells
were noted on review of the blood smear.
• The moderate pleomorphism, occasional reniform nuclear shapes, moderate amounts of cytoplasm, and occasional
erythrophagocytosis allow for histiocytic sarcoma as a less likely differential. So, consider confirming lymphoproliferative
disease with immunocytochemistry or PARR (on splenic aspirate slides or bone marrow aspirate slides if the cells are present
within the bone marrow) or biopsy of an abnormal organ (eg spleen or any lymph nodes that are enlarged) with
immunohistochemistry. Bone marrow aspirate would be recommended to evaluate for leukaemia as this is a poor prognostic
indicator.
• LIVER COMMENTS: The neoplastic cells within the liver are the same as the neoplastic cells present within the spleen
(4000073493) and again are interpreted as most compatible with a large cell or anaplastic lymphoid population;

29. Piper Rossano 11yr FS Lab
• Immunocytochemistry performed
• and final diagnosis was T cell
• hepatosplenic lymphoma
• Treated with chemotherapy for 4 months and
then showed signs of progressive splenic
disease and abdominal discomfort.

30. Hepatosplenic lymphomaHepatosplenic lymphoma
• Hepatosplenic lymphoma is a rare type of T cell lymphoma that
is characterised by splenic, hepatic and bone marrow
infiltration without peripheral lymphadenopathy
• This is an aggressive type of lymphoma with patients
presenting with cytopaenia’s and hypoproteinemia
• Hepatocytotropic T cell LSA- not only hepatic sinusoids but
invasion of hepatic cords (CD11d-)
• In humans, this disease is more often seen in
immunosuppressed patients (organ transplant recipients) and
there has been a link to azathioprine
• CHOP frequently induces remission but this disease is
aggressive and prognosis is poor

31. Koira Livingstone 7yr F Spitz
• Presented with vomiting and elevated liver
enzymes (ALT 916, AST 168, ALP 331 GGT 32)
• On initial ultrasound the liver parenchyma
appeared normal
• Treated symptomatically

32. Koira Livingstone 7yr F Spitz
• Repeat ultrasound 1 week later again showed a
slightly hypoechoic liver with enlarged hepatic
lymph node and enzymes were still elevated
• FNA’s of the liver/LN taken

33. 33
HEPATIC LYMPH NODE AND LIVER ASPIRATES; Ten routinely stained slides
DESCRIPTION: The hepatic lymph node shows good cell recovery. Approximately 80% of cells are medium to
large lymphoid cells with large round, eccentric nuclei and modest volumes of blue-grey cytoplasm. A
juxtanuclear pale zone is evident in the cytoplasm of most cells. Together cell types include 13% small
lymphocytes, 4% neutrophils, 1% plasma cells and 2% macrophages. Several large lymphoglandular bodies are
evident in the background.
The Liver shows islands of quite heavily vacuolated and swollen hepatocytes that are accompanied by large
numbers of lymphoid cells. The majority of lymphoid cells are large, similar to those predominating in the
lymph node aspirates. Much bile pigment and biliary casts are associated with the hepatocytes.
COMMENTS: Lymphosarcoma of large lymphoid cells is evident in both the lymph node and liver. A vacuolar
hepatopathy and cholestasis is also present
Koira Livingstone 7yr F Spitz

34. 34
Koira Livingstone 7yr F Spitz
• Immunocytochemistry diagnosed T cell
lymphoma
• Koira was started on LOPP chemotherapy in
July 2013 and is still alive today!
Koira Livingstone 7yr F Spitz

35. Snowy Dennett 11yr MN Devon Rex
• Presented with a history of unilateral nasal
discharge and sneezing
• FIV positive
• CT and rhinoscopy performed
• after BP + coags were normal
• Samples submitted for cytology
• histology and bacterial/fungal
• culture

36. • CT showed a soft tissue mass
• occupying the left nasal cavit
Snowy Dennett 11yr MN Devon Rex

37. • Macroscopic description: The specimen/s presented for examination are 10 pieces, 5-
8mm, cream-brown.
• Microscopic description: Markedly expanding the nasal mucosa multifocally and
destroying tissue architecture is a dense pleomorphic round cell proliferation. Nuclei
are large, round or indented, and densely basophilic or finely stippled and nucleolated;
cytoplasm is inconspicuous or scant and eosinophilic. Anisokaryosis is moderate and
mitotic index is conservatively 12/10HPF. Individual cell apoptosis is frequent, there
are larger areas of necrosis, haemorrhage and granulation tissue, and there is a variably
mild to moderate infiltrate of neutrophils, small lymphocytes (including follicle
formation), plasma cells and scattered macrophages.
• Diagnosis: Nasal lymphosarcoma - large cell, high grade.
• Comments: Sections show features of an aggressive round cell malignancy assessed as
lymphosarcoma on the basis of cell morphology that includes little cytoplasm. Areas
containing tumour are generally devoid of epithelium, presumably ulcerated;
lymphocytic infiltration of epithelium elsewhere seems to be associated with reactive
follicles rather than tumour. Additional changes are likely secondary to the tumour. IHC
is available to further define the proliferation if necessary.
Snowy Dennett 11yr MN Devon Rex

38. Feline lymphomaFeline lymphoma
• Lymphoma is the most common neoplasm in
cats, represented 30% of feline tumours.
• It is associated with a bimodal age distribution,
with a peak occurring at <4yrs and another at
8yrs of age.
• Unlike canine lymphoma, which is typically
multicentric involving peripheral lymph nodes,
feline lymphoma has a variety of anatomic and
histologic presentations.

39. Feline nasal lymphomaFeline nasal lymphoma
• Seems to be Stage I disease
• FeLV
• 3 original reports using RT as primary Tx shown prolonged ST 40 months.
• Response of 19 cats w nasal LSA to RT and chemotherapy Sfiligoi
2007
– Combination of RT 22-48 Gy with 6 months chemotherapy median PFI 31
months
– 17/19 remission 10/17 remission all period of follow up, 4 local relapse, 3
distant dz
– Negative PF- cribriform plate involvement
• Survival analysis of 97 cats w nasal LSA Haney 2009
– RT, chemo and RT+chemo. MST 536 days
– PF – anemia , + response to Tx and RT>32 Gy
– Which RT protocol? Which chemo?

40. Feline lymphomaFeline lymphoma
• Hodgking’s LSA cats
• Hodgkin's lymphoma in humans is unique among lymphoid
cancers in both its clinical and morphologic presentations.
• In humans, Hodgkin's disease is described as a slowly
progressive, even curable neoplasm of lymphoid tissue that
arises in a single node or chain of nodes and spreads via
contiguous nodes. Splenic and hepatic involvement succeed
nodal disease, and only in the late stages of the disease is the
marrow infiltrated.

41. Feline lymphomaFeline lymphoma
• The disease presents
histologically as a
heterogeneous population of
lymphoid and inflammatory
cells with a minority of
malignant Reed–Sternberg
(RS) cells (and/or variants)
scattered throughout the
tissue.1,6
The presence of RS
cells and their variants is not
pathognomonic of the
disease but is essential for a
histopathologic diagnosis.
•
• Reed Sternberg cells
Text
Reed-Sternberg Cells

42. Feline lymphomaFeline lymphoma
• The clinical presentation is unusual for feline lymphoma and
appears very similar to that of human HD.
• In 95% (19/20) of cases, the cats were presented with either a
single enlarged lymph node (17/20) or two contiguous
enlarged lymph nodes (2/20).
•

43. Feline GI lymphomaFeline GI lymphoma
• Increase incidence from 32% to 72.5% in post
FeLV era
• SI, stomach, mesenteric LNs and liver
• Small cell LSA confined typically to GI tract
• Low Grade GI LSA –T cell, high Grade B-cell
• Large granular cell LSA – aggressive type of
alimentary LSA, thought to be NK origin

44. Feline GI lymphomaFeline GI lymphoma
• Why is diagnosis of alimentary LSA difficult?
– Many reasons for infiltration of immune cells into SI in cat ( infections
such as Mycobacteria, helicobacter, Giardia, Toxoplasma), chronic food
allergies, idiopathic causes and enteric-associated T-cell infiltration are
difficult to distinguish
– Clonality and flow cytometry is useful
• Small –cell LSA:
– slow onset, chronic weight loss
– Palpable ropey thickened intestines
– 10% hypercalcemic
– 78% low cobalamine levels
– Tx Chlorambucil 15 mg/m2for 4 days q3 weeks
– MST 704 days

45. Feline GI lymphomaFeline GI lymphoma
• Large cell alimentary LSA
– acute CS, 80% palpable abdominal mass, weight loss,
obstruction and septic abdomen
• Marked difference between small and large
= diagnosis can be made on FNA
– Prognosis is poor with MST 4-6 months RR 60%
• Abdominal RT as rescue therapy 2011 Parshley
– 11 cats, 2x8Gy response in 10/11 cats MST post RT 211 days

46. Before After
Snowy Dennett 11yr MN Devon Rex

47. • Received COP chemotherapy
• and re-staged once completed
• which showed dramatic
• improvement
• Continued on maintenance
• therapy and is still doing well
• 12 months on
Snowy Dennett 11yr MN Devon Rex

48. Forster Douglass 12yr MN Border Collie
•Presented as a referral for a recurrent oral melanoma

49. 49
• Biopsy report: what are we expecting?Biopsy report: what are we expecting?
• Options for dog?Options for dog?
• a)a) Surgery and melanoma vaccineSurgery and melanoma vaccine
• b) Radiation of massb) Radiation of mass
• c) Carboplatin chemotherapyc) Carboplatin chemotherapy
• d) Lomustine chemotherapyd) Lomustine chemotherapy
• Further diagnosis with histopathology and immunohistochemistryFurther diagnosis with histopathology and immunohistochemistry
Round cellsRound cells
Histiocytic cells
Mast cells
Lymphoma
Plasma
TVT
Epitheliotropic T cell lymphoma Amelanotic melanoma

50. 50
Lip mass. Extensively infiltrating through the submucosa are myriad
round cells with scant amounts of lightly eosinophilic to clear
cytoplasm and no obvious pigment. The cells have atypical lymphoid
appearance with round nuclei containing granular to branched chromatin
and 1 nucleolus. Some of the nuclei are indented while occasional cells
have a slightly larger nucleus. The cells show aggregation around
vessels as well as infiltration into bundles of nerve and skeletal
muscle. The mitotic index is 5. There are scattered interstitial
eosinophils, small dark lymphocytes, occasional plasma cells and
macrophages. Within the overlying haired skin is a similar population of
round cells showing epitheliotropism, and also affecting hair follicles,
sebaceous glands and sweat glands. These cells often have clear
cytoplasm and infiltrate epithelium as individual cells and small
clusters. Affected regions of the epithelium are subtended by plasma
cells, small dark lymphocytes and a few of the atypical lymphocytes.
Distribution of this change within the affected haired skin is not
uniform. The mucosal surface is affected but to a lesser extent.
Neoplastic cells are not seen at mucosal and haired skin margins.
IMMUNOHISTOCHEMISTRY REPORT
The neoplastic lymphocytes within epithelium and deeper tissue are
strongly and uniformly labelled with CD3
Epitheliotropic lymphomaEpitheliotropic lymphoma

51. 51
Epitheliotropic lymphomaEpitheliotropic lymphoma
• Clinical presentation
– Lesions clinically and histologically resemble many
inflammatory skin diseases

52. 52

53. 53
....or neoplastic conditions

54. 54
Scott’s classification
1. Exfoliative
erythroderma
2. Plaques/nodules
3. Ulcerative disease of
oral mucosa
4. Mucocutaneous forms

55. 55
Comparative oncology: Mycosis fungoides
– Mycosis fungoides = epitheliotropic T
cell lymphoma
• MF variants
– Folliculotropic MF
– Pagetoid Reticulosis (solitary form)
(Woringer-Kolopp)
– Granulomatous slack skin syndrome
– Sezary Syndrome
5 year survival
88-100%
5 year survival
24%
Patches and
plaques
<10%
BSA
>10%
BSA
T1
T2
1 + cutaneous tumour T3
Erythroderma T4

56. 56
Epitheliotropic lymphomaEpitheliotropic lymphoma
Histopathology and ImmunohistochemistryHistopathology and Immunohistochemistry
• IMHC: CD3 (CD8+)
Photomicrograph (original
magnification 400Å~) of a punch
biopsy of skin from the preputial
region of Rigby, stained with
periodic acid-Schiff.
Note evidence of invasion of
epidermis and dermis by a
monomorphic population of
malignant lymphocytes
(arrowhead) and epidermal
microabscess (Pautrier’s
microabscess) (arrow).

57. 57
Epitheliotropic lymphomaEpitheliotropic lymphoma
DiagnosisDiagnosis
• Histopathology
– 50% (7/14) of oral cases were conclusively
diagnosed with histopathology alone (Nemec et al,
2012)
• early stages can have marked mixed
inflammatory infiltrate, late stages > B
lymphocytes
• >50% there is a mix of lymphocyte cell size
reported
• IMHC
– humans: 5-10% lymphoid neoplasia cannot be
diagnosed with use of histopathology and IMHC
• PARR
– T cell receptor (TCR) gamma rearrangement
– Sensitivity 80-95%, Specificity 96-100%
Clinical features
Histopathology
Immunohistochemistry
Clonality testing
Clinical follow up
and repeat biopsy

58. 58
• Thoracic radiographs, abdominal ultrasound, LN biopsy
• Lomustine (CCNU) and prednisolone
• Monitoring
• Response: complete remission 7 months*
– Lomustine ORR 78-83% (17-32% CR, 50-61% PR)
– Median duration 88-94 days (Risbon et al, 2009, Williams et al, 2008)
• Ionised hypercalcaemia noted at three months
– Anal sac adenocarcinoma, surgery post staging
– Melphalan and NSAIDS
– Complete remission
• ETL progressive disease at 7 months, despite recommencing
lomustine
• Euthanasia one week later due to ruptured splenic mass and
haemabdomen
Forster’s Epitheliotropic lymphomaForster’s Epitheliotropic lymphomaStaging and treatmentStaging and treatment
Other therapies
Surgery
Radiation
Retinoids
Interferon
Phototherapy
Systemic chemotherapy
Novel therapies

59. 59
take home message

60. 60
New clinical trial
• Brain tumours and Melanomas

61. 61
Drug Loading and Targeting

62. Axial sequential MRI scans showing brain tumor (white irregular mass) prior to EDV treatment
Corresponding MRI scans showing almost complete elimination of tumor mass post-treatment with 5 doses of Canine
EGFR
EDVsDox