Case Report – Lumps under the jaw

Case Report

As always, names and some data have been altered to protect patient privacy. The facts are the facts, though.

Ranger is a 10 year old male neutered mixed breed dog weighing about 45#. He’s been feeling lethargic for a few days. Today, he wouldn’t eat and seems to not want to get up at all. The owner also reports that he was drinking a bit more water than normal before he got lethargic. Lastly, the owner mentions that she felt a couple of bumps under the jaw.

Physical Exam

Temp: 101.9F

Pulse: 100 beats per minute

Respirations: 20 breaths per minute

Attitude: lethargic

Hydration status: mildly dehydrated

Body condition: obese

Eyes: normal

Ears: normal

Oral Cavity: Stage 2 periodontal disease (moderate tartar and mild to moderate gingivitis)

Heart: normal

Lungs: normal

Abdomen: slightly enlarged spleen

muscles/bones: normal

Skin: normal

Lymph nodes: all significantly enlarged (generalized lymphadenopathy)

Initial assessment:

Enlarged lymph nodes can indicate immune reaction, inflammation, and neoplasia (cancer).

Enlarged spleen can come from the same problems as the enlarged lymph nodes.

Excessive drinking can happen for lots of reasons: kidney disease, behavioral problems, cancer, toxins, diabetes

Basic Diagnostics & Results
Blood chemistry – Slightly higher than normal calcium. This can indicate kidney disease, cancer, vitamin D toxicity, or hyperparathyroidism.

Complete Blood Count – High white blood cell count, mainly neutrophils. Neutrophils are infection fighting cells. Interestingly, none of them looked like they had been fighting an infection. The lymphocyte count (another type of white cell) was a touch low. These changes can happen when an animal is stressed by being in the hospital or from general illness. These abnormalities aren’t playing an immediate role in the case at this point in time.

Urinalysis – A small amount of protein was found in the urine. That can come from kidney damage of a few different types. It’s important to remember this, but again, not much bearing on the case immediately at hand.

Heartworm test – Negative

Fecal parasite exam – Negative

Additional Diagnostics Ordered

Chest x-rays – Normal, no sign of cancer in the lungs. Heart was normal size and shape

Abdomen x-rays – Enlarged spleen. The rest was normal

Critical Diagnostic Test
Needle aspirate (“biopsy”) of several lymph nodes
800px Canine lymphoma 1
Path description:

Cellularity is high and consists of moderate numbers of intact lymphoid cells, occasional neutrophils, and few macrophages. The lymphoid population is comprised predominantly of large lymphocytes (12 to 15 micrometers) with round to oval nuclei, granular chromatin, 1 to 3 pale nucleoli, and scant basophilic cytoplasm. Few small lymphocytes are noted.

Translation:

There were lots of cells for the pathologist to evaluate. As expected from a lymph node sample, there were lots of lymphocytes. These are white blood cells responsible for a lot of immune functions. They were larger than normal. They had round or oval shaped nuclei, meaning the core of the cell. It should normally be round. Chromatin is bunched up DNA. It shouldn’t look clumpy or granular. A nucleolus is a tiny little sphere inside the nucleus. We expect to see just one, if we can see it at all. These cells had as many as three. The lack of cytoplasm, which is a gel inside the cell, indicates a bigger than normal nucleus. That’s also not a good sign.

Official interpretation: large cell lymphoma

Lymphoma is a cancer arising from lymphocytes. It can happen in a lymph node or another organ that has lymphocytes in it. Common sites are liver, spleen, and intestinal tract. I’ve seen lymphoma in the bone marrow and kidneys, too. This is a very destructive disease in most cases. It’s a bad diagnosis.

When we talk about lymphoma, there are details that make a big difference in how well a pet will do with treatment. The first thing we have to do is “Stage” the cancer. We have to determine if it’s only in one node, many nodes, other organs, or bone marrow. The staging is divided up as follows:

  • Stage I: Disease confined to a single lymph node
  • Stage II: Regional lymphadenopathy (confined to one side of diaphragm)
  • Stage III: Generalized lymphadenopathy
  • Stage IV: Hepatosplenomegaly (with or without lymphadenopathy)
  • Stage V: Bone marrow, CNS, or other extranodal site involvement
  • Substage

    a: No clinical signs

    b: Clinical signs of illness

For Ranger, the presence of a large spleen suggests that we might well have lymphoma in the spleen as well as the lymph nodes. That automatically puts him at Stage IV. The general lethargy and poor appetite, as well as drinking more water than normal, means he has clinical signs, so that’s Substage b. Incidentally, the high calcium levels in the blood are one of the things we can see with lymphoma, and that’s what made Ranger drink more water than normal.

Ranger has Stave IVb lymphoma.

Treatment Options

We can treat lymphoma a variety of ways. It is a disease that we can’t usually cure, so treatment is aimed at putting the cancer into remission. Left untreated, lymphoma is generally fatal within a month or so from the time of diagnosis. (In some special cases, it’s less swift.)

The best way to do that is with chemotherapy. We can’t put our pets through the same level of chemo as people go through. They get too sick and don’t do well. People have the ability to understand that they’re sicker so that they can be better or cured on the other side of the treatment period. Dogs and cats just don’t tolerate it that well. When we do a course of chemo for pets, they don’t lose their hair. They generally don’t get very sick at all, and usually just a bit of nausea/vomiting and diarrhea are the side effects we see. Depending on the chemo drug, there can be far worse side effects, but I wouldn’t say that they’re terribly common. For most pets, we can achieve remission for about 1 year. After that, a second remission is much harder to obtain and maintain. The average is around a year of good quality of life for dogs and cats.

There is an intermediate step between full chemo and doing nothing that can often buy a few months of good quality of life. We use a drug called Prednisone (or Prednisolone). It’s a glucocorticoid steroid that we also use for allergic diseases. The dose for “chemo” is a LOT higher. In most cases, we’re able to shrink down the lymph nodes and create a ‘remission’ for 2-3 months. I’ve had a few dogs go as long as 8 months with prednisone alone. They’re the exception rather than the rule, sadly. A few have only gone a few weeks.

When cost isn’t an issue, I strongly encourage owners to have chemo for their pets. There are several oncologists in our area that are excellent. They’ve managed quite a few of our lymphoma cases very well. Those pets had good quality of life for about a year.

When cost is an issue, I also encourage owners to treat with prednisone. Often, that extra month or three of time with their pets allows owners to come to terms with what’s happening. The pets feel reasonably good — we ALWAYS maintain quality of life first and foremost — and the treatment is easy and inexpensive.

When faced with this nasty diagnosis, the important thing to remember is that there are options that provide good quality of life for the time that remains. I fully support owners who choose either treatment method. I also support owners that elect to euthanize if clinical signs are already unfairly hard on their pet, or if side effects of the chemo are intolerable.

Ranger’s owner elected to try the Prednisone therapy. It has only been a few days of treatment so I’m not yet sure how this is going to turn out, but we’re on our way.

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1 Comment

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One response to “Case Report – Lumps under the jaw

  1. Chris Miner

    Sending positive energy to Ranger and good thoughts to his people! This is the hard part of loving our pets. Dr. Hutchinson, I know you will do absolutely everything in your power for Ranger! Please keep us in the loop.