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Cutaneous Lymphosarcoma- Update

by MKinoshita - October 13, 2009

Hi Steve,
This is an update from post of Aug 11/09.
12 yr old FS Brittany Spaniel (21 kg) dx cutaneous lymphosarcoma (epitheliotrophic T cell lymphoma).
Currently on Chai Hu Jia Long Gu Li Tang 3 g once daily, Qing Ying Tang 1 gram once daily (added when skin lesions worsened - but not helping). Xian Fang Huo Ming Yin ointment topically on skin lesions. Pred 2.5 mg EOD. Vitamin A/D, Hollywood Safflower Oil. (Weaned off SMS and Hoxsey)
When started on QYT - energy improved, breathing better. But skin lesions did not improve -dropped dose thinking too Damp - skin worse. Now more patchy alopecia on extremities - nose, legs, nose crusts. (also broke her nail jumping out of car 2 weeks ago) (Blood defic?) Ulcerated, erythemic lesions on trunk - licks them. Used to have lots on ventrum but they are resolving - now more on lateral and dorsolateral body. Start with slightly raised erythemic lesion, then scab then ulcerate (moist lesion) then yellow crust/scab forms over. Oldest lesion (inguinal area) - no longer erythemic/ulcerated - has slightly raised, firm lavender appearance (Phlegm/Blood Stasis?) with ring of erythemic ulceration about 3 cm around it. Lesions respond to XFHMY ointment but more appear. Owner thinks they started to appear more when took off Hoxsey. Pre-scap peripheral lymph nodes enlarged still but others smaller. App excellent but gradual, slow wt decrease. Hind end bit weaker (slips on tile floor).
Pulse - soft, deep, rapid.
Tongue - red/lavender underside, no coat, redder tip of tongue, flabby tip of tongue.
I think I need something more moving for Blood Stagnation/Stasis and possibly to tonify more (improve Blood Defic). Can the Xian Fang Huo Ming Yin be added orally to the protocol, should it replace Chai Hu Jia Long Mu Li Tang ...?? Should I add Hoxsey back since the owner thinks the skin worsened when we took her off? Take off QYT totally (only got improved energy when started it).
Thanks.
Michelle Kinoshita

by naturevet

October 13, 2009

Hi Michelle,

Certainly you should follow the lead of the patient and use the formulas that help the most. So Hoxsey and XFHMY are fine. If there are no active GB points, then maybe this is not a CHJLGMLT case.

I haven't found pred particularly gratifying in cutaneous lymphoma. But I have been pleased with the results of metronomic doses of cytoxan, in tandem with the herbs. We give a dose every three days. Dr. Erin Bannink on this list gave me the dose. If memory serves, it's about 25 mg for a 30 pound or so dog every three days. Maybe if we're lucky she'll suggest a dose for you, given that you've listed weight and breed.

Hope that helps you out.

Steve

by bannink

October 15, 2009

Michelle and Steve,

I am glad to hear the metronomic cytoxan was helpful. The dose I use is 25mg/m2 every other day. Cytoxan comes in 25mg tablets and you should NOT split the tablets (Although I have had it compounded into capsules for smaller patients.) So, if your patient is 21kg, that would be 19mg every other day. I would recommend starting with 25mg every 3 days and seeing how she does with that. Monitoring is very important. Main side effects include neutropenia, which can be cumulative, and sterile hemorrhagic cystitis (due to acrolein metabolite which can irritate bladder lining). This is what you should recommend and the client should be willing to do if taking this route of treatment:

1) CBC before starting treatment. Neutrophils need to be at least 3,000 K/mcL
2) Start q3d treatment. Use chemo gloves to administer and routine chemo precautions. I usually have owners give it in the morning and let them outside to urinate frequently (if possible) throughout the day to be cautious. Some oncologists use lasix to dilute the urine, but I don't and, with careful screening and encouraging frequent urination, have not had any serious problems in my patients. If owner notices stranguria or blood in urine, stop cytoxan and recheck CBC and check urinalysis and urine culture (for secondary infection). If patient develops cystitis, they should not receive any more Cytoxan. I usually switch to oral leukeran in those cases.
3) Recheck CBC 2 weeks after starting and then again 2 weeks later. If normal, then recheck CBC and urinalysis (to screen for hematuria before clinical signs develop) q4 weeks.
4) If neutrophils drop below 3000 K/mcl (or 2500 K/mcL if you are very careful with monitoring) then stop cytoxan until counts recover. Also, no chemo if platelets are <100,000.

Don't let it scare you. Most patients do great. But you must respect the chemo!

Good luck!

Erin

by Marta

February 27, 2010

Hi Erin,
I have a similar case, and have one question - what is the response to oral leukeran and what dose do you use?
Thanks!
Marta

by bannink

March 1, 2010

Marta,

CCNU (Lomustine) is really the drug of choice for mycosis fungoides. Cytoxan was brought up because Steve asked me for a metronomic dose for one of his patients and I was not excited about metronimic CCNU. Does your patient have urinary tract issues which are making you shy away from Cytoxan?

Erin

by Marta

April 16, 2010

Hey!
I never saw this reply. Sorry it took me so long to check on it!
My client is one of those who really does not want aggressive chemo, so I thought I could go on the Cytoxan and expect less side effects. The patient is only on Vits A&D and Hoxsey Formula right now and is pretty comfortable.
What do you think?

by naturevet

April 16, 2010

I have to say the metronomic dose of cytoxan worked really well, presumably because the herbal formula was also working well enough to do a lot of the 'heavy lifting'. If you have something on board that is doing that for you, then the low dose cytoxan approach might work. I had Erin figure my dose out for me. I believe it's based on body surface area. If you let us know the weight (maybe in a new post), then Erin might be able to give you a dose (if she feels comfortable doing that in a public forum).

S

by landauvet

January 8, 2013

Safe for cats? I have a cat losing the battle now. She has been on CHJLGMLT, topicals, hoxsey, vit A/D3. Also has been on 10 mg pred bid. New lesions on skin forming which are raw and irritated.
Thanks,
Kevin Landau

by naturevet

January 9, 2013

Hi Kevin,

As far as I know the drug is safe for cats. A regular pharmacology book should answer that question, but in metronomic doses, there should be precious few signs of toxicity.

Steve

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