Atypical Visceral Lymphoma | Nor Cal Vet Emergency + Specialty Hospital, Bay Area

Radiographic findings in patient with atypical visceral lymphoma.

By Bill Rivers, DVM, PhD,
Diplomate American College of Veterinary Radiology

5/25 Initial presentation to Dr. S. Grier on emergency service from Westborough Pet Hospital for history of progressive decreased appetite, intermittent vomiting, intermittent melena, decreased energy, over past month. Decreased HCT and elevation of all white blood cell counts reported for rDVM blood work. Started on empirical prednisone, cerenia, and baytril by rDVM.

INVESTIGATION

5/26 Internal medicine referral to Dr. J. Sergeeff, DVM, Diplomate ACVIM. Regenerative anemia noted on blood panel. Abdominal sonography performed showed thickened stomach wall, hypoechoic nodules in liver, hypoechoic area in omentum caudal to stomach, slight thickening of small bowel wall. Owner declined gastric biopsy and opted for gastric ulcer treatment. Pepsid and sucralfate added to Rx.

7/13 Re-check exam with Dr. J. Sergeeff. Had been doing well but recent decreased appetite, increased thirst, lethargy. Blood panel shows marked elevation SAP, ALT, slight elevation total and direct bilirubin. Repeat abdominal sonography by Dr. Sergeeff showed more numerous hypoechoic nodules in liver, progression in stomach wall thickening, and scant free peritoneal fluid.

7/16 Thorax, abdomen radiographs submitted to Dr. B. Rivers: Decreased pulmonary vasculature size, moderate bilateral pleural fluid, possible sternal lymphadenopathy, marked hepatomegaly, and probably mural thickening of gastric wall, slight loss of peritoneal serosal detail noted. Diagnostic Impressions: Dehydration/hypovolemia vs. electrolyte imbalance. Possible sternal lymphadenopathy (metastatic or primary neoplastic; benign reactive less likely). Pleural effusion, ddx: neoplastic (pleural metastasis, thoracic nodal infiltration), secondary to hypoproteinemia if present; pleuritis, chylothorax, hemothorax, pyothotrax are unlikely in comparison. Gastric wall thickening ddx: neoplastic (lymphoma, carcinoma, other cell type least likely) more likely than benign IBD. Hepatomegaly ddx: neoplasia (metastatic from stomach vs. concurrent primary), vacuolar change varying local severity +/- focal nodular hyperplasia (if diabetic or cushingoid). Slight peritoneal effusion ddx: neoplasia (peritoneal/omental metastasis, nodal invasion); secondary to hypoproteinemia if present, peritonitis, secondary to liver dysfunction. Suggestions for further patient management: Consider further evaluation with transthoracic sonography to further assess for sternal lymphadenopathy and obtain pleural fluid tap for analysis/cytology; sonographic guided abdominal fluid tap for analysis/cytology, endoscopic or sonographic guided FNA of the gastric wall thickening; sonographic guided FNA vs. core biopsy of the liver (after coagulation profile for latter); current blood panel, UA.

DIAGNOSIS

Pleural fluid centesis by Dr. Sergeeff: modified transudate on cytology, no bacterial growth on culture screen.
Ultraosound guided FNA of liver by Dr. Sergeef: Large cell lymphoma.
Presumptive diagnosis is visceral lymphoma with gastric, liver, and thoracic (pleural/nodal) involvement.

THE CHALLENGE

Visceral lymphoma presents typically for the liver as a diffuse enlargement of the liver without nodularity. A nodular presentation is uncommon.

TREATMENT

Owners opted for palliative prednisone therapy.

7/29 Follow-up thorax radiographs submitted to Dr. B. Rivers: Resolution of pleural effusion. Sternal lymphadenopathy is no longer present. Unremarkable radiographs.

RESULTS

Patient pleural effusion and probable sternal lymphadenopathy resolved with palliative prednisone Rx. Anorexia also resolved. SAP and ALT elevations were improved but persistent. Anemia recurred. Patient returned to rDVM 7.30.15 for further palliative care.

DISCUSSION

Visceral lymphoma presents typically for the liver as a diffuse enlargement of the liver without nodularity. A nodular presentation is uncommon. The recurrent anemia presumably was due to gastric ulceration associated with presumed gastric infiltration. Palliative prednisone therapy elected by owner achieved at least initial resolution of pleural effusion presumed secondary to pleural and/or thoracic lymph node involvement.

THORAX VD: Before and after, two weeks time elapsed.

About the author

Bill Rivers

Bill assists Nor Cal Vet doctors and technicians with the more advanced ultrasound examinations and complex x-ray studies. He has a particular interest in radiographic interpretation as well as both thoracic and abdominal sonography.