Treatment of Feline Gastrointestinal

Small-Cell Lymphoma With Chlorambucil

and Glucocorticoids
Gastrointestinal (GI) lymphoma is the most frequently diagnosed form of lymphoma in the cat
and is categorized into two distinct forms based on the size of neoplastic lymphocytes.
Treatments for both large- and small-cell GI lymphoma have been described previously; how-
ever, multiple chemotherapy protocols were used, a minimal amount of histopathological
characterization was provided, and, in most studies, the majority of diagnoses were obtained
via endoscopic pinch biopsies. Twenty-eight cats (24 with full-thickness intestinal biopsies)
were diagnosed with small-cell GI lymphoma and treated with a combination of chlorambucil
and glucocorticoids. The majority of cases were strongly CD3+, and many displayed epithe-
liotropism. The overall clinical response rate was 96%, with a median clinical remission dura-
tion of 786 days. Follow-up identified seven cats with relapsed disease—all of which were
treated with a rescue protocol of cyclophosphamide and glucocorticoids; the response rate
was 100%, and four of the 28 cats were diagnosed with a second malignancy.
J Am Anim Hosp Assoc 2010;46:413-417.

Timothy J. Stein, DVM, PhD, Introduction

Diplomate ACVIM (Oncology) Feline lymphoma presents in a multitude of anatomical forms, with gas-
MacKenzie Pellin, BS trointestinal (GI) lymphoma being the most frequent form of presenta-
tion.1-3 Although the GI form of the disease is most frequently
Howard Steinberg, VMD, PhD, encountered, few reports exist that focus solely on treatment of the GI
Diplomate ACVP form.4-7 Often the treatment and outcome of GI lymphoma are included
with other forms of the disease, making information regarding treatment
Ruthanne Chun, DVM,
of feline GI lymphoma difficult to interpret and compare.
Diplomate ACVIM (Oncology)
Feline GI lymphoma appears to occur as one of two major types, with
a portion of cats being affected by a more indolent, small-cell (lympho-
cytic) form of lymphoma and others having a more aggressive, large-cell
RS (lymphoblastic) form of lymphoma.4,8 Treatment of large-cell feline GI
lymphoma with multiagent chemotherapy protocols has led to median
remission durations of 140 to 213 days.6,7 Longer disease-free intervals
(DFIs) of 365 and 510 days were reported by Fondacaro et al, although
only two (18%) of 11 cats in this study achieved a complete response.4
The purpose of this study is to describe the treatment of feline GI
small-cell lymphoma with chlorambucil and glucocorticoids within a
well-defined case population.

From the Departments of Medical Materials and Methods

Sciences (Stein, Pellin, Chun) University of Wisconsin-Madison Veterinary Medical Teaching Hospital
and Pathobiological Sciences (Steinberg), (UWVMTH) medical records were searched for cats histologically diag-
School of Veterinary Medicine,
University of Wisconsin-Madison,
nosed with small-cell GI lymphoma and treated with chlorambucil and
2015 Linden Drive, glucocorticoids between 2001 and 2008. Information recorded from the
Madison, Wisconsin 53706. records included signalment, clinical pathology abnormalities at time of

JOURNAL of the American Animal Hospital Association 413

414 JOURNAL of the American Animal Hospital Association November/December 2010, Vol. 46

Table

Grading of Hematological Toxicities Resulting in Treatment Delays for Cats With Small-Cell
Gastrointestinal Lymphoma Treated With Chlorambucil and Glucocorticoids

Hematological Toxicity Grade I Grade II Grade III Grade IV

Neutropenia <LLN* to 1500/µL 1499 to 1000/µL 999 to 500/µL <500/µL

Thrombocytopenia <LLN to 100,000/µL 99,999 to 50,000/µL 49,999 to 25,000/µL <25,000/µL

Note: Table modified from VCOG-CTCAE9

* LLN=lower limits of normal

diagnosis, results of pretreatment thoracic radiographs and Results

abdominal ultrasound, date of diagnosis, biopsy method, Twenty-eight cats met the entry criteria for this study.
date of treatment initiation, hematological abnormalities on Fifteen (54%) cats were castrated males, and 13 (46%) cats
follow-up clinical laboratory reports, duration of first were female (one intact, 12 spayed). Of the 28 cats, 19
response, duration of follow-up, and duration of survival. (68%) were domestic shorthair, five (18%) were domestic
Hematological toxicities were graded according to the crite- longhair, two (7%) were domestic medium hair, one (3.5%)
ria established by the Veterinary Cooperative Oncology was Siamese, and one (3.5%) was Bengal. The median age
Group9 [see Table]. Results of postmortem evaluations were at diagnosis was 13 years (range 4 to 20 years). The median
included when available. When possible, biopsy specimens weight at time of diagnosis was 4.15 kg (range 2.7 to 6.6
were reviewed by one pathologist (Steinberg) to confirm the kg).
diagnosis of intestinal small-cell lymphoma. In addition, Available for review were the results of hematological
when an adequate amount of biopsy tissue remained, testing in 24 cats from the date of diagnosis; 20 of the cats
immunophenotyping was performed using antibodies had abnormalities present. No hematological abnormalities
against CD3, CD20, and CD79a. were consistent between cats, and none were severe enough
All cats were treated with chlorambucil administered at 20 to warrant changes to the proposed therapeutic regimen.
mg/m2 orally once every 2 weeks. The chlorambucil dose cal- Diagnostic imaging was performed on 27 of the 28 cats.
culated for each cat was rounded to the nearest whole tablet Thoracic radiographs were available for 19 cats, with
formulation (2-mg tablets). The type, dose, and frequency of reported abnormalities being mild enlargement of the car-
glucocorticoid administered were determined according to diac silhouette in eight cats, sternal lymphadenomegaly in
the treating clinician’s preference, although 17 (60%) of the four cats, and bronchial disease in two cats. Abdominal
28 cats were started on an immunosuppressive dose of gluco- ultrasonography was performed on 27 (96%) of the 28 cats
corticoid and gradually tapered to every-other-day therapy. prior to diagnosis, with the most frequent finding being
Cats were considered to be in clinical remission if their intestinal thickening in 22 (81%) of the cats. Details of the
clinical signs (i.e., vomiting, diarrhea, weight loss) had remaining five ultrasounds either gave no description of
resolved. Repeat abdominal sonograms were reviewed intestinal thickness or were unavailable for review.
when available to document clinical remission or relapse of Gastrointestinal small-cell lymphoma was diagnosed via
disease. In cats responding to treatment, the duration of first histological examination of full-thickness surgical biopsy in
clinical remission was defined as the time between the first 24 (86%) cases and by endoscopic biopsy in two cases. The
treatment and disease progression or return of clinical signs. remaining two biopsies were obtained by the referring vet-
For cats considered to be out of clinical remission and erinarian, and the sampling method was not recorded. Of the
receiving a second therapy, the second clinical remission 28 cases, 18 (64%) had histopathology specimens available
time was calculated as the number of days between the date for review at the UWVMTH. After review of the 18 avail-
of rescue chemotherapy initiation and the date they were able slides, all cases were consistent with small-cell, or low-
considered to be out of a second clinical remission. For sta- grade lymphocytic, lymphoma. The histological description
tistical analyses, cats still in clinical remission at the time of of epitheliotropic lymphoma was given for 12 (67%) cases,
data analysis or cats lost to follow-up before disease relapse equivocal epitheliotropism was noted in two (11%) cases,
were censored at the time of the last known contact. and no observable epitheliotropism was seen in the remain-
The Kaplan-Meier product-limit method was used to ing four (22%) cases. Immunohistochemical analysis was
estimate clinical remission duration. performed on 18 cases, with 17 (94%) staining positive for
November/December 2010, Vol. 46 Feline Gastrointestinal Lymphoma Treatment 415

the CD3 T-cell marker and one staining positive for the 35, 38, and 74, respectively. The time lengths between diag-
CD20 B-cell marker. Fourteen (82%) of the 17 CD3 (+) nosis of small-cell GI lymphoma and the secondary malig-
cases were described as having epitheliotropism. nancies were approximately 520, 542, 864, and 1456 days,
All cats initially received chlorambucil at a dosage of 20 respectively.
mg/m2 orally once every 2 weeks. Because of client prefer- Of the 28 cats in the study, seven (25%) died, 10 (36%)
ence, two cats were switched to 20 mg/m2 chlorambucil were alive, and 11 (39%) were lost to follow-up at the time
orally once every 3 weeks. Seventeen (60%) of the 28 cats of analysis. Of the seven cats that died, two had no evidence
received prednisone or prednisolone at 2 mg/kg orally once of lymphoma at the time of death (based on necropsy results
daily initially for 1 week; two cats received approximately for one and a lack of clinical signs in the other), one cat died
1.5 mg/kg orally once daily for 1 week; five cats were start- of septic cholangiohepatitis with GI lymphoma present on
ed at 1 mg/kg orally once daily for 1 week; one cat received postmortem, and four cats had unknown causes of death.
1.5 mg/kg orally every other day; and one cat received 1 Nine (32%) of the 28 cats were documented with disease
mg/kg orally every other day. All cats had their pred- recurrence based on the return of clinical signs and/or ultra-
nisone/prednisolone dosages tapered to 1 mg/kg orally sonographic changes consistent with relapse. Seven of the
every other day until disease relapse or progression of dis- nine cats with relapsed disease were treated with oral
ease. Two cats received dexamethasone, initially at cyclophosphamide at a calculated dosage of 200 to 250
immunosuppressive dosages and then at dosages that were mg/m2 given on days 1 and 3 out of every 2 weeks (25 mg
gradually tapered over the course of 3 weeks. given Monday and Wednesday every other week) and pred-
Treatment with chlorambucil and a glucocorticoid result- nisolone (5 mg every other day). All seven of the cats res-
ed in clinical remission in 27 (96%) of 28 cats, with a medi- cued with cyclophosphamide responded based on resolution
an duration of 786 days for the first clinical response of clinical signs and normal abdominal palpation. Of the
[Figure 1]. seven cats with relapsed small-cell GI lymphoma, three
The median number of chlorambucil doses received per were in clinical remission at the time of death due to unre-
cat was 23 (range 5 to 110). Three treatment delays were lated disease, three were in clinical remission at the time
reported as a result of hematological toxicities in cats treat- they were lost to follow-up, and one had disease recurrence
ed with chlorambucil, one episode of a grade II thrombocy- based on return of clinical signs. The durations of second
topenia, one episode of a grade II neutropenia, and one clinical remission for the three cats that had died of unrelat-
episode of a grade III neutropenia. None of the recorded ed disease were 239, 283, and 418 days. Three cats were lost
toxicities required any additional therapy, and all resolved to follow-up at 116, 162, and 946 days. The final cat
relapsed 241 days after starting cyclophosphamide and
prednisolone.

Discussion
This retrospective study supports prior findings that chlor-
ambucil and a glucocorticoid result in a long duration of
clinical remission for cats with GI small-cell lymphoma.
Kiselow et al reported a duration of 897 days for first clini-
cal remission in cats achieving a complete response, which
compares favorably with the DFI reported herein of 786
days.5 Similarly, the study by Fondacaro et al reported a
median DFI of 615 days.
In the current study, chlorambucil was administered at 20
mg/m2 every 2 weeks compared to 2 mg orally every 2 to 3
days. The administration of chlorambucil on a biweekly
basis rather than daily or every other day has been reported
previously in humans with chronic lymphocytic leukemia
Figure 1—Overall duration of first remission for cats with
and lymphocytic lymphoma with similar results compared
GI small-cell lymphoma treated with chlorambucil and
glucocorticoids. to continuous single-agent or combination chemotherapy
regimens.10,11 The ability to administer chlorambucil to cats
on a biweekly basis rather than every 2 to 3 days while
with treatment delay. Four (14%) of the 28 cats developed a maintaining a prolonged duration of clinical remission is a
second malignancy during the study period. Diagnoses logistic advantage.
included a mammary carcinoma, gastric mast cell tumor, One of the strengths of the current study is the high per-
intraabdominal carcinomatosis, and poorly differentiated centage of full-thickness surgical biopsies over endoscopic-
oral squamous cell carcinoma with metastasis to regional obtained biopsies. Acquiring full-thickness surgical biopsies
lymph nodes. The total numbers of chlorambucil doses allows for a more thorough histopathological characteriza-
received by cats developing a second malignancy were 34, tion of lesions due to the increased amount of tissue avail-
416 JOURNAL of the American Animal Hospital Association November/December 2010, Vol. 46

able for review. This results in a more complete under- relative infrequency of medicating the cat while maintaining
standing of the disease pathology, as evidenced by this a favorable clinical outcome.
study’s ability to additionally classify lesions as epithe- Shortcomings of this study include the lack of thorough
liotropic in 12 (67%) of the 18 samples available for slide staging in all cats and the reliance upon resolution of clini-
review. A previous report suggests that endoscopic pinch cal signs to signify disease remission. Also, the lack of stan-
biopsies are inferior to full-thickness biopsies obtained via dardized recheck examinations hinders the determination of
exploratory laparotomy for differentiating between inflam- adverse side effects associated with treatment. Finally, the
matory bowel disease and small-cell GI lymphoma.12 large number of cats lost to follow-up, even with attempts
Potential drawbacks of full-thickness biopsies include being made to contact owners, is disappointing. All three of
increased expense, time, and invasiveness/morbidity asso- these limitations are inherent in a retrospective study
ciated with obtaining them. None of the cats in this study design. Even with these study limitations, we are able to
had intra- or postoperative complications that resulted in a conclude that the treatment of feline small-cell GI lym-
delay of treatment initiation. phoma with the combination of chlorambucil and glucocor-
The majority of cases for which adequate tissue ticoids is well tolerated and associated with a long initial
remained for slide review and immunohistochemical analy- remission time, similar to previous reports.4,5
sis had a histological diagnosis of epitheliotropic T-cell Future studies may focus on the optimal dosing schedule
lymphoma. The combination of histological description, for chlorambucil in the treatment of small-cell lymphoma.
immunophenotype, and response to therapy has not been All three studies on GI small-cell lymphoma utilized differ-
reported for cats with small-cell GI lymphoma. The majori- ent treatment schedules, yet all were associated with a pro-
ty of cases of GI lymphocytic lymphomas in a report by longed, first clinical response duration. The dose intensity of
Fondacaro et al were described as having epitheliotropism, protocols used may be increased, as the hematological toxi-
though no immunohistochemical analysis was performed.4 cities associated with the reported treatment protocols
Carreras et al reported on 10 cases of feline epitheliotropic seemed to be low, with few treatment delays being necessary.
intestinal lymphoma, all of which were described as con- Altering the dose intensity would allow us to determine if
sisting of small to intermediate-sized lymphocytes, and all more frequent treatments or higher dosages would lengthen
stained positive for presence of the CD3 T-cell marker.13 median remission times. However, as cats with GI small-cell
A median survival time of approximately 330 days was lymphoma treated with chlorambucil already have prolonged
reported for nine of the cats that received prednisone with or clinical remission durations, the ability to detect significant
without other chemotherapeutics. Multiple chemotherapy differences in remission durations may be difficult.
drugs were used in the treatment of these cats; however, no Alternatively, it would be interesting to determine if con-
cat received chlorambucil, no standardized protocol was tinuous dosing with chlorambucil is required for the pro-
reported, and no toxicity information was available. That the longed duration of remission times. Cats respond well to the
majority of feline GI lymphomas are of T-cell origin with currently published treatment protocols and in many cases
epitheliotropism is similar to a previous report characteriz- receive chlorambucil for many months. The use of continu-
ing canine GI lymphoma.14 Unfortunately, the response to ous chemotherapy in human studies has been associated
therapy and clinical outcomes in those cases of canine GI with an increased risk of developing a second malignancy or
lymphoma were not reported. Additional studies are needed hematological abnormality. Alkylator-purine analog combi-
to determine if a clinical significance is associated with nations may increase the risk of therapy-related myeloid
epitheliotropism versus nonepitheliotropism in feline small- malignancy.15 An increased frequency of secondary malig-
cell GI lymphoma. What is clear from this and previous nancies, including epithelial neoplasms, was noted in cats
studies on feline GI lymphoma is the more prolonged remis- receiving long-term chlorambucil for indolent chronic lym-
sion times associated with the small-cell form of the disease phocytic leukemia compared to a nontreated case popula-
compared to the more typical large B-lymphocyte form of tion.16 Because chlorambucil is a slow alkylator, chronic
the disease.4,5,8 use results in constant insults to normal DNA, and carcino-
Although not a primary objective of this study, seven cats genesis is a risk. We did not compare the incidence of devel-
with relapsed disease were treated with cyclophosphamide, oping a second malignancy in cats with other forms of
with a 100% response rate and a median clinical remission cancers associated with prolonged survival times; therefore,
time of 241 days. To our knowledge, this is the first study to no statements may be made regarding an increased risk of
report on the response to rescue chemotherapy for cats with secondary malignancy development associated with contin-
relapsed small-cell GI lymphoma. uous chlorambucil treatment. However, it is striking that
The strengths of this study include the high percentage of four (14%) of the 28 cats evaluated developed a second
cats diagnosed with full-thickness surgical biopsy of the malignancy during their course of treatment.
intestine, the histopathological and immunohistochemical Another potential explanation for the development of a
characterizations of the majority of cases included in the secondary malignancy in this population of cats is that pro-
study, and the reporting on the responses of cats with longed survival increases the chances of a mutation occur-
relapsed disease to rescue therapy. Additionally, one of the ring in another cell type that could contribute to cancer
advantages of the currently reported dosing scheme is the formation. Finally, chronic continuous chemotherapy may
November/December 2010, Vol. 46 Feline Gastrointestinal Lymphoma Treatment 417

alter the immune system’s ability to identify and destroy 16. Mahony OM, Moore AS, Cotter SM, et al. Alimentary lymphoma in
abnormal cells. Second malignancies in this study included cats: 28 cases (1988-1993). J Am Vet Med Assoc 1995;207:
1593-1598.
a poorly differentiated oral squamous cell carcinoma with 17. Zwahlen CH, Lucroy MD, Kaegel SA, et al. Results of chemothera-
metastasis to the regional lymph nodes, intraabdominal car- py for cats with alimentary malignant lymphoma: 21 cases (1993-
cinomatosis, mammary carcinoma, and a gastric mast cell 1997). J Am Vet Med Assoc 1998;213:1144-1149.
tumor. The second malignancies reported here are similar to 18. Valli VE, Jacobs RM, Norris A, et al. The histologic classification of
the aforementioned study reporting an increased frequency 602 cases of feline lymphoproliferative disease using the National
Cancer Institute working formulation. J Vet Diag Invest 2000;12:
of developing epithelial-based malignancies while being 295-306.
treated continuously with chlorambucil.16 19. Veterinary Co-operative Oncology Group: Common terminology cri-
teria for adverse events (VCOG-CTCAE) following chemotherapy or
Conclusion biological antineoplastic therapy in dogs and cats v1.0. Vet Comp
Our finding of long initial remission times, particularly a Onc 2004;2:194-213.
10. Knospe WH, Loeb V Jr, Huguley CM Jr. Proceedings: Bi-weekly
median first remission time of 786 days, for cats with GI chlorambucil treatment of chronic lymphocytic leukemia. Cancer
small-cell lymphoma treated with chlorambucil is consis- 1974;33:555-562.
tent with those previously published. Dosing delays due to 11. Knospe WH, Loeb V Jr. Biweekly chlorambucil treatment of lym-
hematological toxicities were minimal in this study and pre- phocytic lymphoma. Cancer Clin Trial 1980;3:329-336.
vious reports; however, the finding of second malignancies 12. Evans SE, Bonczynski JJ, Broussard JD, et al. Comparison of endo-
scopic and full-thickness biopsy specimens for diagnosis of inflam-
in the current study is concerning and warrants additional matory bowel disease and alimentary tract lymphoma in cats. J Am
examination. Vet Med Assoc 2006;229:1147-1150.
13. Carreras JK, Goldschmidt M, Lamb ML, et al. Feline epitheliotropic
References intestinal malignant lymphoma: 10 cases (1997-2000). J Vet Intern
11. Vail DM, Moore AS, Ogilvie GK, et al. Feline lymphoma (145 Med 2003;17:326-331.
cases): proliferation indices, CD3 immunoreactivity and their associ- 14. Coyle KA, Steinberg H. Characterization of lymphocytes in canine
ation with prognosis in 90 cats receiving therapy. J Vet Intern Med gastrointestinal lymphoma. Vet Pathol 2004;41:141-146.
1998;12:349-354. 15. Morrison VA, Rai KR, Peterson BL, et al. Therapy-related myeloid
12. Gabor LJ, Canfield PJ, Malik R. Immunophenotypic and histological leukemias are observed in patients with chronic lymphocytic
characterization of 109 cases of feline lymphosarcoma. Aus Vet J leukemia after treatment with fudarabine and chlorambucil: results of
1999;77:436-441. an intergroup study, cancer and leukemia group B 9011. J Clin Oncol
13. Louwerens M, London CA, Pederson NC, et al. Feline lymphoma in 2002;20:3878-3884.
the post-feline leukemia virus era. J Vet Intern Med 2005;19: 16. Dighiero G, Maloum K, Desablens B, et al. Chlorambucil in indolent
329-335. chronic lymphocytic leukemia. N Engl J Med 1998;338:1506-1514.
14. Fondacaro JV, Richter KP, Carpenter JL, et al. Feline gastrointestinal
lymphoma: 67 cases (1988-1996). Eur J Comp Gastroenterol
1999;4:5-11.
15. Kiselow MA, Rassnick KM, McDonough SP, et al. Outcome of cats
with low-grade lymphocytic lymphoma: 41 cases (1995-2005). J Am
Vet Med Assoc 2008;232:405-410.