Small Cell Lymphoma vs Inflammatory Bowel Disease: The great debate

[myrnafaye]

Have his pancreas checked.

 

[mina]

 
Have his pancreas checked.

Thanks.  If it they sent his blood sample to where I think they did, they'll also check pancreatic enzyme levels (amylase, lipase) as well as liver enzymes (AST, ALT, GGT, Alk Phos).  

 

[myrnafaye]

Where I live I think the Pancreatic values come from a lab in Texas, the other values are part of a chem panel that is run locally.  Keep us posted.

 

[stephenq]

 
I'm going through the same issue now with my cat Tigger.  He is around 10 years old and started having inflammatory bowel issues about 18 months ago.  We tried diet changes (hydrolyzed protein, hypoallergenic food) and different medications (cyclosporine, prednisone shots) to no success for about the first 9 months of his illness (during which he was having diarrhea constantly and grooming to the point of creating sores on himself), but thankfully, since August 2014, his symptoms are now being controlled on 3.5 mg of prednisolone orally each day plus Natural Balance Limited Ingredient duck and pea dry food and wet food.  He vomits much less now (1-2 times/month), does not excessively groom anymore, and his stools are well-formed.  He's got a great appetite and is active, energetic, and his usual affectionate self.

Unfortunately, when I took Tigger to the vet yesterday, I found out that he's lost 2 pounds since his August checkup.  In August he was a slightly-overweight 13 lbs; now he is a somewhat-skinny 11.  His gums also looked pale to the vet, so she suspects anemia.  With the combination of weight loss and potential anemia, the vet immediately started talking about the possibility of a GI lymphoma and the diagnostic workup for that.  We did a CBC, CMP, and TSH (the normal senior wellness package - we couldn't get urine, so no urinalysis) and are awaiting results.  Obviously the bloodwork won't conclusively rule in or rule out anything, but if he is anemic the MCV should tell us whether we're dealing with a megaloblastic anemia (suggesting a B12 deficiency - which I guess doesn't have neurological manifestations in cats like in humans? but would make sense if his terminal ileum is being affected by IBD) vs. a microcytic or normocytic (or slightly macrocytic) anemia of chronic disease.

For those of you who've had kitties with a small cell lymphoma - did they have obvious symptoms/behavioral changes other than weight loss when they were diagnosed?   

Sadly i went through all of this.  B12 deficiency is common with IBD,  Weight loss is also common with serious IBD, but if it isn't controlled by the pred then basically not good, and it could have progressed to lymphoma.  I would suggest an ultrasound to look for the degree of intestinal inflammation, and to see if there is lymph node involvement.  If the nodes are bd you may be able to get a cancer diagnosis via needle aspirate, fairly easy, light anesthesia.  Another option - possibly, is a full thickness biopsy or an endoscopy, but you would have to discuss the usefulness of this while your cat is on the Pred.

Another option with un-arrested weight loss, that many vets will do on suspicion of lymphoma is to use Leukeran.  Leukeran is used either for advanced IBD that doesn't respond to steroids, or small cell lymphoma which is the normal extension/morphing of IBD.  It is a form of chemo, about 80% of cats tolerate it fine enough, if your cat is in the 20% that don't then you have to discontinue therapy.  Leukeran is as far as you can go without a positive diagnosis of lymphoma, should you even want to try the other drugs.

If there is continued weight loss while on the pred read on - note also that 3.5mg is a very low dose. My cat was on 5mg daily and that was still considered a low dose as he had both kidney and heart issues, and given the severity of your cat's situation, i would personally rather try 5-10mg daily for a few weeks if my only other options were Leukeran or biopsy.  One issue with oral Pred is that since the cat is having nutrient absorption issues, he may be having trouble absorbing the pred.  Another option is Dexamethosone by Sub Q injection as it bypasses the intestines entirely.

In a less common twist, when my cat stopped responding to the pred and also to the sub Q Dex, we finally got a positive diagnosis by needle aspirate of the lyph nodes, but not of lymphoma but of mast Cell cancer, which is not treated with Leukeran but with another drug.

Please keep us updated.

 

[myrnafaye]

I agree with Steven that 2.5 is a VERY light dose of pred.  My Obi is on 5mg for IBD and he is doing very well. I also agree that it is worth bumping up the pred.

 

[puck]

1. If a radiologist performed his U/S, ask for an estimate to have an ultrasound guided large needle biopsy done of the intestines. Non-surgical, may need mild sedation, as the needles are big. Sometimes cells are poorly formed, and the pathobiology result is inconclusive, but you get a definitive answer if the cells are formed well enough for the pathobiologist to see, stain, and differentiate.

2. Consult with an oncologist about their initial exam fee and a lymph node fine needle aspirate (FNA) if the large needle biopsy isn't an option with a radiologist. They can grade the lymphoma, if confirmed with the FNA, and formulate a chemo plan.

3. Responding that well and fast to prednisolone strongly resonates with IBD. Many patients need it when a stressful event occurs, such as visitors, new home, travel, vet visit, owners out of town, etc. Some folks have seen their IBD cats do best on a combo of daily pepcid, daily to every other day pred, limited ingredient diet, and cisapride/reglan or other combo of GI motility meds during stress, or once the IBD is chronic in geriatric care of their long-term treated kitties.

Keeping his hyperthyroidism regulated is a huge controlling factor for GI health. When not regulated, metabolism, absorption, acid release, enzyme release, and blood glucose are affected, as all are "ran/triggered" by hormones of the endocrine system. Endocrine outta whack, then GI outta whack. If healthy enough for radioactive therapy, that would be ideal. If has lymphoma, not ideal candidate.

Glad he's fattening up and getting his groceries! Good ole Vitamin P (vet slang pred) boosts the appetite and squashes inflammation like a boss, no comparison.

The big thing is ensuring a hyperthyroid cat on steroid does not have any sign of heart or renal disease yet. Hyperthyroidism leads to both heart and renal disease. Pred is hell on the heart and kidneys if already less than healthy. Seeing as his T4 was deemed high recently and his dose needed adjusting, he may have had some detrimental effect to the heart, kidneys, or blood pressure already.

Good luck with diagnostics on your boy! Treating the symptoms without a definitive diagnosis isn't a bad thing. He's responding well to steroid therapy, so that limits the diagnoses to a few possibilities already. If that's enough answer for you, and your vet(s), to continue prescribing and managing while his quality of life is better, it is not a wrong choice.

 

[kittygirl123]

Thank you so much for sharing @StephenQ,  and @EmilyAnn

I recently posted a new thread but thought I would share my situation as it is very challenging...

my 12 year old male has lost 1 pound in recent months and has been severely constipated.  He has had a long history of constipation.

All lab values were normal, GREAT appetite, and playful.  If anything aggressive so we thought/hoped just hyperthryroid but not the case.

An ultrasound revealed "probable" SCL - she based that on the history of constipation vs diarrhea, yet my vet said she never heard this.

My vet advised against the biopsy and suggested 5 mg prednisolone. We also switched him to Royal Cannin Fiber Response - and he can finally "go"!  
Unfortunately he is a challenge to medicate and the BCP Vet chews are 1.50 or so each??  I also understand Leukeran is quite expensive.  My vet suggests starting with just the pred at 5 mg.

With no other symptoms whatsoever aside from weight loss (since the diet change) I am probably in denial but finding it hard to want to treat him aggressively.

My inclination is to just give the diet time and see if he gains weight so as not to mask the SCL with pred,  but they said it is unlikely and he will become more symptomatic with diet alone.

However, i have read that "novel protein" diets can assist.....do not know which are best however.  Royal Cannin suggested High Energy or Hydrolyzed Protein.  However, we want to make sure he is not constipated so this is going to be a tough switch.   

Pretty scared to wait to treat SCL "if" that is what it is but the differing opinions from the docs makes it confusing.  He just seems SO happy but I know he is too thin, and cats are resilient.  Thank you all!
 

 

[myrnafaye]

Kittygirl, I cant tell you what to do but I give both my cats Nature's Variety limited ingredient diet.  They either get rabbit, or salmon, because both are novel proteins, and the rest of the formulas are either high in fat or not novel protein.  You might wish to look at the fat content in the food you have been giving your cat; in people, and I suspect in cats also, a high fat diet can result in all sorts of GI issues.  For bulk I give them both 1/4 tsp metameucil mixed with a bit of water, and right into the wet food.  They dont even know it is there.  Pred may help his appetite and you can try grinding it up in a very small amount of food  - mixing well - and making sure he eats t hat before you give him more. Make sure he gets enough water!  that goes a long way to prevent constipation.  Canned food has a high water content also.  I dont know about the hydrolyzed protein RC food - I get t he theory behind it but wonder about it...Does anyone else here have any experience with it, in helping cats with GI disease?  I have to say I have been quite pleased with NV; it is pricey but I figure it is better to pay more for food than it is to pay for vet visits.

 

[kittygirl123]

@myrnafaye  he has absolutely no problem with appetite. That is why we previously thought hyperthyroidism and I am scared to have him on pred. He's a good eater as is. As mentioned, his symptoms were just the weight loss with constipation.  Thanks for the suggestions. Unfortunately, I spent years trying various canned foods with miralax or metamucil, he knows it is there and hates canned food.  He has since rescued.  He will starve himself or attack the other 3 kitties until he gets his dry.  
For him, being comfortable is most important and being able to "go" while putting weight back on. That RC fiber response is like a miracle! It is just hard to know if to start leukeran or not given the situation or try a different novel protein/dry.

It appears the RC high energy or hydrolyzed protein are the ones for IBD or SCL.  

 

[myrnafaye]

Yikes, Wow!  I never heard of a cat being so adamant about his dry food!  well, OK, they are known to be finicky.  I am also surprised by the metameucil issue.  Thats a shame. Well, it sounds like you are managing well.  I can understand your hesitancy about the pred, but it is also a potent anti inflammatory.  Perhaps @StephenQ will share his thoughts on the pred and food issues?

 

[stephenq]

 
Pretty scared to wait to treat SCL "if" that is what it is but the differing opinions from the docs makes it confusing.  He just seems SO happy but I know he is too thin, and cats are resilient.  Thank you all!
 

Hi

I'm going to try and help untangle this a bit for you. If you cat has SCL - and i did say the word "if" - then you are 100% past the point where you can treat this with diet.  Diet can help, but diet alone will not get SCL into remission, and if you don't get it into remission, your cat is going to die a lot sooner than necessary.  With remission, its possible your cat could have a few years, and easily a year.

Since treatment for SCL and advanced IBD (usually defined in part by weight loss that can't be reversed through diet) is the same, a diagnosis by biopsy isn't imperative.  A biopsy is major surgery, may not yield a definitive diagnosis, but can assist owners in treatment decisions.

A cat that has SCL generally wants to be on Pred and  Leukeran to give the cat the best chance at remission, however starting just with the pred doesn't sound unreasonable, especially if the cat puts on weight.

Generic Pred in pill form is very cheap.  But if you can't pill your cat, can't use pill pockets, can't trick him into eating it, then your more expensive option may be the only way to go. 

But here's my big question:  your cat has a long history of constipation.  Cats do not live with a long history of untreated SCL.  In addition to that, you started a high fiber diet and the constipation is resolved.  I'm assuming the vet saw thickening of the bowel and loss of layering on the ultrasound?  That would support a diagnosis of SCL or IBD.

 

[kittygirl123]

Hi @StephenQ  !  Thank you so much for chiming in! I will try the pill pockets from Petsmart today and also pick up a few more chews in case.

I started him with just 1/2 a chew (2.5 mg) vs 5 because his appetite is SO good I am afraid he is going to eat so much food.  His only symptom is weight loss with constipation.

The report from Ultrasound vet says "Small Intestine - poor wall layer differentiation of some sites without overall increased width; some sites with prominent wall layers and normal wall width; all measures <0.3cm

Diagnosis 1. Diffuse infiltrative process of the small bowel - probably lymphoma, IBD Is possible too  2. Mild mesenteric lymphadenopathy

Yet she said "your sharing his history of constipation is what leads me to think more likely lymphoma, but likely the indolent type"....  she said a biopsy is far more likely to diagnose for sure vs needle aspiration.

He has been constipated for years, and had a bought of awful diarrhea 2 years ago when we switched him to Eukaneuba which helped bind him.  Since then the constipation has come back with a vengeance.  The RC has been great but hard to know if will last given his history.  He is such a great eater that pred concerns me.  Thank you!!

 

[stephenq]

 
Hi @StephenQ  !  Thank you so much for chiming in! I will try the pill pockets from Petsmart today and also pick up a few more chews in case.

I started him with just 1/2 a chew (2.5 mg) vs 5 because his appetite is SO good I am afraid he is going to eat so much food.  His only symptom is weight loss with constipation.

The report from Ultrasound vet says "Small Intestine - poor wall layer differentiation of some sites without overall increased width; some sites with prominent wall layers and normal wall width; all measures <0.3cm

Diagnosis 1. Diffuse infiltrative process of the small bowel - probably lymphoma, IBD Is possible too  2. Mild mesenteric lymphadenopathy

Yet she said "your sharing his history of constipation is what leads me to think more likely lymphoma, but likely the indolent type"....  she said a biopsy is far more likely to diagnose for sure vs needle aspiration.

He has been constipated for years, and had a bought of awful diarrhea 2 years ago when we switched him to Eukaneuba which helped bind him.  Since then the constipation has come back with a vengeance.  The RC has been great but hard to know if will last given his history.  He is such a great eater that pred concerns me.  Thank you!!

Ok well 2.5mg Pred is a very  low dose, and if your vet wants him on 5mg then i would do what the vet suggests.  Don't confuse pred use with his appetite.  When you have IBD/SCL, the reason you lose weight is because that infiltrative/inflamed response is preventing the intestines from absorbing nutrients.  He can have a HUGE appetite and still lose weight, that's part of the problem of IBD/SCL, you can't arrest the weight loss with food by itself.

 

[kittygirl123]

Thanks @StephenQ  it is so wonderful to have that explained to me, I am so thankful!  I have been questioning the absorption given the appetite.  I will be picking up more meds today and give the full dose. He is a bit of a bully (3 other kitties) and misbehaves as is, so I really hope that does not exacerbate his attitude problem. Curious if you agree with one vet over the other that constipation is more likely SCL?  Just so fearful to not treat it but also hate to in advance.  Thank you!

 

[stephenq]

 
Thanks @StephenQ  it is so wonderful to have that explained to me, I am so thankful!  I have been questioning the absorption given the appetite.  I will be picking up more meds today and give the full dose. He is a bit of a bully (3 other kitties) and misbehaves as is, so I really hope that does not exacerbate his attitude problem. Curious if you agree with one vet over the other that constipation is more likely SCL?  Just so fearful to not treat it but also hate to in advance.  Thank you!

Hey

Well SCL is usually an outgrowth of inflammatory bowel so there really is no such thing as treating it too early, especially if there has been weight loss.  The earlier you can get your cat into remission, the longer your cat may live, and live symptom free.  I think diarrhea is a more common symptom of SCL, but the literature lists constipation as a symptom.  based on my personal experience and conversations with my vets, i wouldn't have picked constipation as the primary symptom of SCL.

I think the more common process is, various GI symptoms, diarrhea common, treated for as long as possible with diet etc, when that stops working (and weight loss ensues) you go to Pred

Your ultrasound sounds like it could support either diagnosis.

 

[kittygirl123]

Great info @StephenQ  !  I am just concerned if the pred can mask SCL how/when do we know if to add Leukeran?  I would imagine if he gains weight we will not know if the disease is progressing?
TIA

 

[stephenq]

 
Great info @StephenQ  !  I am just concerned if the pred can mask SCL how/when do we know if to add Leukeran?  I would imagine if he gains weight we will not know if the disease is progressing?
TIA

It's not that the pred masks the SCL per se, it treats it although pred is better at treating IBD than SCL.  Generally if you take the two step approach (first pred, then leukeran, as opposed to the both at the same time approach), you know its time to add the leukeran when he starts losing weight again.

Weight Gain = disease not progressing, disease is going into remission. 

Weight loss = disease is progressing or shifting from IBD to SCL despite pred therapy.

When we talk about Pred masking the disease, that is in the context of it making it hard to tell what a biopsy would reveal while on pred therapy as the pred masks the illness from the biopsy.    The pred doesn't mask the disease from the body, it treats the body.  In other words, the diagnostic value of a biopsy is greatly reduced if you are successfully treating the disease, because what you're looking for in the biopsy is no longer there.

 

[kittygirl123]

I am so grateful for your knowledge and sharing @StephenQ  ! I did know about the biopsy challenges on pred but was under the impression it would also promote weight gain regardless of the disease thus making it too late to treat.  I am going to try the 5mg of pred alone for 6 weeks and re-assess.  I hope that is not too long to wait.  His weight loss was gradual but has increased in recent months.

He lost an additional 9 ounces in 4 days, my guess was the change of the diet and he was able to "go" 3x in one day when he could not at all for days, so we will weigh him again later and hope for the best.  It's hard to know how often to take them in, weigh them etc. etc.  

 

[stephenq]

 
I am so grateful for your knowledge and sharing @StephenQ  ! I did know about the biopsy challenges on pred but was under the impression it would also promote weight gain regardless of the disease thus making it too late to treat.  I am going to try the 5mg of pred alone for 6 weeks and re-assess.  I hope that is not too long to wait.  His weight loss was gradual but has increased in recent months.

He lost an additional 9 ounces in 4 days, my guess was the change of the diet and he was able to "go" 3x in one day when he could not at all for days, so we will weigh him again later and hope for the best.  It's hard to know how often to take them in, weigh them etc. etc.  

My bill is in the mail :-)

For assessing weight gain or loss, i can't recommend more highly a baby scale like this one .  Rather than wait for (and possibly pay for) that weight check at the vet, you can do it at home.  I also recommend you keep a written log so you can see the trend precisely over time, and i also recommend that you weigh on the same day each week, so the interval of time is consistent. 

In other words if you weighed on different days, you could have a mess like this:

7oz gain over 8 days

3oz gain over 2 days

10oz gain over 11 days, helpful yet confusing right (?)

Versus

5oz gain over 7 days

6oz gain over 7 days

8oz gain over 7 days, then the trend is clear.

Even though both examples are the same # of days and the same amount of gain, the trend (more weight gain each week) is only clear in the second example.

 

[kittygirl123]

Good idea @StephenQ  !  I had the same one picked out at Walmart so will get it tomorrow. Of course as an anxious mama we want to know every hour, but that does us no good.  Ideally, how often should a kitty like this be weighed?  I really feel like he looks thinner in recent days but I could be over analyzing and also he is shaved from the ultrasound.  I do feel his spine though.