Jarrod Troy ISUCVM Class of 2014 416 Billy Sunday Rd Apt 101 Ames IA 50010 Mentor Stephanie Caston DVM DACVSLA Iowa State University Equine Surgery Service Case Previously Presented by R David Whitley DVM MS DACVO ID: 917567
Download Presentation The PPT/PDF document "MULTICENTRIC T-CELL RICH B-CELL LYMPHOMA..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
MULTICENTRICT-CELL RICH B-CELL LYMPHOMA IN A MULE
Jarrod Troy ISU-CVM Class of 2014416 Billy Sunday Rd Apt. 101Ames IA 50010Mentor: Stephanie Caston, DVM, DACVS-LAIowa State University Equine Surgery Service
Case Previously Presented by R David Whitley, DVM, MS, DACVO
International
Equine Ophthalmic Consortium
West
Palm Beach, FL
April 2011
BILATERAL THIRD EYELID LYMPHOMA IN A MULE
Whitley EM, Murphy M, Haynes JS, Caston S, Madron M, Waller KR, Tofflemire K, Whitley
RD
Slide2SIGNALMENT
“Hank”25 year old castrated Mule495-kg (1090-lb) Presented at Iowa State University Equine Surgery Service for bilateral surgical removal of third eyelids
Slide3HISTORY
12/14/10: 6 week duration of progressive bilateral third eyelid swelling.
Slide4INITIAL CLINICAL FINDINGS
Bilateral bulbar and palpebral conjunctival thickeningThird eyelid protrusionMild bilateral exophthalmosPatent nasolacrimal ducts Mild ocular discharge
ParameterHank’s ValueReference IntervalTemperature (F
0/C0)98.7/37.1
99.0-100.8
/37.2-38.1
Heart Rate (beats/minute)
32
28-40
Respiratory Rate (breaths/minute)
24
10-14
Slide5DIAGNOSTIC PLAN
Skull RadiographsDorsoventral & Lateral Oblique Views Collimated to Mid-Skull; Oblique Views Collimated to OrbitsFindingsBilateral exophthalmosHeterogeneous soft tissue masses (~7cm) rostroventral to globesGuttural pouches partially air filled
Slide6PROBLEM LIST
Bilateral Bulbar and Palpebral Conjunctival ThickeningThird Eyelid ProtrusionBilateral ExophthalmosMild Ocular DischargeGuttural pouches partially air filledTemperature DecreasedTachypnea
Slide7DIFFERENTIAL DIAGNOSIS
Bilateral Bulbar/Palpebral Conjunctival ThickeningForeign Body NeoplasiaBlepharitisExophthalmosThird Eyelid ProtrusionTraumaNeoplasiaBlepharitisGuttural Pouch Empyema
Bilateral ExophthalmosNeoplasiaOrbital Cellulitis
TraumaMild Ocular DischargeNeoplasiaConjunctivitisExophthalmosTrauma
Slide8DIFFERENTIAL DIAGNOSIS
Guttural pouches partially air filledTraumaNeoplasiaGuttural Pouch EmpyemaSlightly Decreased TemperatureCold StressPoor PerfusionTrauma
TachypneaStressPainPneumoniaNeoplasia
Slide9DIAGNOSIS
Presumptive DiagnosisSevere, Bilateral Inflammation of Third Eyelid and Palpebral ConjunctivaPossible Mass in the Guttural Pouch Area
Slide10TREATMENT PLAN
Palliative TherapyBilateral Surgical Removal of Third EyelidsEyelids were submitted for HistopathologyHome Treatment InstructionsAnalgesia/ Anti-inflammatoryPhenylbutazone (4.4mg/kg, PO, SID for 7 days, then 1-2 gram as needed to decrease swelling or discomfort)Topical antibiotic ointment NEOMYCIN/POLYMYXIN B/BACITRACIN ZINC EYE OINT 3.5 (BID until tube is empty)Clean discharge/blood from eyes with wet paper towel
Bloody discharge normal for 1-2 days post-op
Slide11OUTCOME 1
“Hank” was discharged from hospital with Home Treatment InstructionsThird Eyelids were submitted for Histopathology
Slide12HISTOPATHOLOGY RESULTS
Both third eyelids, lacrimal gland, and adjacent conjunctiva were effaced by an infiltrative, non-encapsulated, poorly demarcated neoplasm The neoplasm was composed of densely packed with a pleomorphic population of round cell sheets. Mitotic figures are 3-5 per 400X field.
Moderate Anisocytosis/Anisokaryosis.
Slide13HISTOPATHOLOGY RESULTS
Neoplastic cells do not extend into the overlying, intact conjunctival epithelium. Neoplastic cells extend to many tissue margins.Microscopic Diagnosis Third Eyelid Conjunctival LymphomaImmunohistochemical staining was requested to identify cell lineage
Slide14IMMUNOHISTOCHEMISTRY RESULTS
Results:Predominant population of cells were B-lymphocytes (CD79a-positive)Small number of scattered T-lymphocytes (CD-3-positive)DiagnosisB-cell lymphoma
CD79a-Positive Cells
(B-Cells)
Immunohistochemical Staining
CD79a Positive Cells
Indicate B-Lymphocyte Lineage
CD-3 Positive Cells Indicate T-Lymphocyte Lineage
Slide15OUTCOME 2
12/29/12: “Hank” was readmitted to ISU Equine Surgery ServiceDecreased conditionWeight LossSwelling at site of third eyelid removalHistory12/14/12: Bilateral Third Eyelid RemovalBiopsy/Histopathology of Third EyelidsDx: B-Cell Lymphoma
Slide16CLINICAL FINDINGS
Physical ExaminationBilateral lower eyelid/conjunctival swelling. Bilateral ocular discharge Poor dilation and inability to examine fundus of the Left Eye Solid vitreous face and posterior lens luxation of Right EyeSubmandibular Lymph Nodes enlargedMultiple movable, semi-firm masses at Thoracic Inlet/Pelvic Area - Not noted at previous examMild inspiratory stridor at rest
Parameter
Hank’s ValueReference IntervalTemperature (F0/C0
)
99.0/37.2
99.0-100.8/37.2-38.1
Heart Rate (beats/minute)
36
28-40
Respiratory Rate (breaths/minute)
16
10-14
Slide17DIAGNOSTIC PLAN
Rectal ExamNo Abnormalities notedAbdominocentesisSlightly cloudyProtein = 2.2 g/dLNeurology ExamNo Abnormalities notedCBCSlight Anisocytosis of RBCNo other abnormalities noted
Endoscopy of Upper AirwayArytenoids obscured by ventral displacement of the roof of the pharynxPurulent material found in the Left Guttural Pouch Lateral Compartment.
Unable to enter Right Guttural Pouch due to Swelling/ScarringDue to worsening of clinical signs the owner elected for humane euthanasia and necropsy
Slide18NECROPSY RESULTS-GROSS
Orbit ConjunctivaBilaterally Swollen approximately 3cm x 2cmRight Guttural Pouch200-mL of thick, white/yellow exudate Left Guttural PouchModerate amount of friable material. Multiple 1-10mm nodules caudal to pouchCranial Mediastinal Lymph Node
Enlarged and moderately firm. Diameter 10cm
Slide19NECROPSY RESULTS-GROSS
Left Caudal Lung LobeWhite 7cm noduleOn cut surface, there were areas of concentric thickening around luminal structuresMesenteryPedunculated 10-15cm diameter white/yellow massMultiple non-pedunculated, white/yellow masses were also present.Gross Morphological Diagnoses
Multifocal LymphadenopathyGuttural Pouch Empyema
Slide20NECROPSY RESULTS HISTOPATHOLOGY
Pituitary Gland (Pars Distalis & Pars Intermedia)Expanded by well-demarcated, non-encapsulated infiltrative neoplastic mass of densely packed round cell sheets High number of mitotic figures (28/10hpf) and abnormal nuclei & nucleoli changesLymph NodeDiffusely enlarged, with increased numbers of germinal centers; large lymphocytes expanding germinal centers
Lung Parenchyma, Palpebral Conjunctiva, Eye, & Adipose TissueTissues were expanded/effaced by Neoplastic Cells similar in morphology to those described in the Pituitary Gland
Slide21NECROPSY RESULTS IMMUNOHISTOCHEMISTRY
Pituitary GlandScattered cells stained positively for T-Lymphocytes (CD-3) and for B-Lymphocytes (CD79a).Eyelid MassApproximately 90% of neoplastic cells were positive for B-Lymphocytes (CD79a) A few scattered cells were positive for T-Lymphocytes (CD-3)
CD-3 Positive (T-Lymphocyte)
CD79a Positive (B-Lymphocyte)
Slide22FINAL DIAGNOSIS
T-Cell Rich B-Cell LymphomaGrave PrognosisMost horses die or are humanely euthanized within 6 months of clinical onsetCommon secondary tumor of palpebral conjunctivaOften associated with multicentric lymphoma
Slide23T-CELL RICH B-CELL LYMPHOMA
Clinical SignsOften Related to loss of organ function from Lymphocyte Infiltration/Mass ObstructionAnorexia; Emaciation; Lymph Node Enlargement (~2/3 of Cases)
Ocular Manifestation of Multicentric LymphomaInfiltration of upper, lower and third eyelids, conjunctiva, orbit, and globe. Retinal Detachment. Common secondary tumor site for lymphoma
Slide24T-CELL RICH B-CELL LYMPHOMA
Treatment OptionsLimitedTransient improvement in generalized formsCytotoxic drugs, immunomodulators, corticosteroidsLong term response is poorSurgical resection of tumorsSometimes curative or significantly prolong survival
Humane euthanasia
Slide25FURTHER READING
Germann SE, Richter M, Schwarzwald CC, Wimmershoff J, Spiess BM. Ocular and multicentric lymphoma in a young racehorse. Vet Ophthalmol. Sep 2008;11 Suppl 1:51-56Meyer J, Delay J, Bienzle D. Clinical, laboratory, and histopathologic features of equine lymphoma. Vet Pathol. Nov 2006;43(6):914-924.Reed S, Bayly W, Sellon D.
Equine Internal Medicine. 2nd ed: Saunders; 2004.Barnett K, Crispin S, Lavach J, Matthews A. Equine Ophthalmology.2nd ed: Saunders; 2004. Kelley LC, Mahaffey EA(1998). Equine Malignant Lymphomas: Morphologic
and Immunohistochemical Classification. Vet Pathol 35: 241
Slide26ACKNOWLEDGEMENTS
MentorStephanie Caston, DVM, DACVS-LAPictures Provided ByElizabeth Whitley, DVM, PhD, DACVPR. David Whitley, DVM, MS, DACVOStephanie Caston, DVM, DACVS-LA
Kenneth Waller, DVM
PathologyElizabeth Whitely, DVM, PhD, DACVPJoseph S. Haynes, DVM, PhD, DACVPMolly D. Murphy, DVM, PhDRadiologyKenneth Waller, DVM