C09970959 / invoice 10000

Reason: non ambulatoryPerformed by RSHHistory:Bella, 8 y 8m, FS, Dogue de Bordeaux is being managed for multicentric B cell LSA, commenced CHOP 19/12/25.13/12/25: Bella presented to WestVets Anstead for a week history of hyporexia (refusing dry food but would eat anything else) and submandibular lymphadenopathy. Examination noted submandibular lymphadenopathy. FNA of submandibular node was performed and cytology shows reactive lymph node with benign salivary gland sampling. Cytology Reference: 205 - 11425MICROSCOPIC: Smears are of sparse to high nucleated cellularity. Smears contain variable population of cells. Most smears indicate lymph node sampling, with approximately 50% small mature lymphocytes, approximately 30% intermediate lymphocytes and the remainder large lymphocytes with scattered plasma cells. Two smears from the right-hand side contain a similar mixed population of lymphocytes admixed with low numbers of plump spindle cells and individual to small aggregates of polygonal cells with large amounts of light blue, often finely vacuolated cytoplasm (well-differentiated salivary epithelium). The two smears also contain lakes of pink to blue material.INTERPRETATION: Reactive lymph nodes, with benign salivary gland samplingCOMMENT: The lymphoid population is mixed with a few plasma cells, and is most consistent with a reactive population. I note the presence of salivary gland epithelium as well as the pink to blue materialit is unclear whether this represents salivary gland sampling or potentially proteinaceous material as may be observed in lymph node oedema. Is possible that sample salivary gland in this area may be cystic? Findings are not consistent with a sialocele.This case has been evaluated in collaboration with Dr Brett Stone.16/12/25: Bella was then presented to BVSC for dental assessment. Examination noted generalised lymphadenopathy and cytology of peripheral nodal aspirates show multifocal large cell LSA. Blood profile showed lymphocytosis 5.22 (reference 1.05-5.1), monocytosis 1.76 (reference 0.16-1.12), and thrombocytopenia 67 (reference 148-484). Biochemistry noted increased SDMA 15. Blood smear assessment noted abnormal lymphocytosis with circulating abnormal intermediate to large lymphocytes consistent with stage five lymphoma.Examination under anaesthetic noted splenomegaly and multiple gingival mass. Multiple upper incisor extractions performed. Lab Ref:25-59656448 - VETNOSTICS CBC Hb 138 g/L (130-200) Plat ClumpedRCC 5.9 x10*12/L (5.5-8.4)Hct 0.41 (0.37-0.55)MCV 69 fL (61-77)MCH 23 pg (21-26)MCHC 337 g/L (324-363)WBC 12.1 x109/L (5.3-14.9)Neut 4.6 x109/L (3.1-10.3) Neut % 38Lymp 6.5 x109/L (0.9-4.1) Lymp % 54Mono 0.7 x109/L (0.2-1.0) Mono % 6Eos 0.24 x109/L (0.10-1.20) Eos % 2Baso 0.00 x109/L (< 0.11) Baso % 0The red cells appear essentially normal. Platelet numbers appear normal on blood film examination. However, platelet clumping in the EDTA specimen prevents measurement of absolute count. Lymphocytes are heterogeneous, consisting of a mixture of small mature lymphocytes and occasional abnormal intermediate to large lymphocytes with small amount of mid-blue cytoplasm and irregularly round nucleus with fine chromatin and 1-2 inconspicuous nucleoli. There are circulating abnormal intermediate to large lymphocytes, most consistent with stage V lymphoma in context of the clinical history and cytology results.The erythron and thrombon appear sound at present.Glucose 5.04 mmol/L 3.89 7.95IDEXX SDMA 15 µg/dL 14Creatinine 97 µmol/L 44 159Urea 7.2 mmol/L 2.5 9.6BUN: Creatinine Ratio 18Total Protein 60 g/L 52 82Albumin 27 g/L 22 39Globulin 33 g/L 25 45Albumin: Globulin Ratio 0.8ALT 60 U/L 10 125ALP 99 U/L 23 212Lab Ref:25-59656189SPECIMEN SITE: FNAB left submandibular, left popliteal and left prescapular lymph nodes (3 slides in total)MICROSCOPIC: Slides are highly cellular, well prepared and similar in overall appearance. There are a predominance (greater than 80%) of monomorphic appearing large lymphocytes which have central to eccentric nuclei, stippled chromatin, singular or multiple visible nucleoli and typically with negligible amounts of moderately blue cytoplasm. Some cells display minor focal peri-nuclear cytoplasmic pallor and/or minor cytoplasmic vacuolation, occasional mitoses are seen in this population and remaining cells are primarily small mature lymphocytes.INTERPRETATION: MULTIFOCAL LARGE CELL LYMPHOMA.COMMENT: The predominance of lymphocytes as described are, in my opinion, indicative of lymphoma. Please contact the laboratory if you wish to add on CD3 and PAX-5 immunocytochemistry (panel code VBT) in an effort to phenotype this lymphoid population.19/12/25: Vincristine @0.7mg/m2 (N: 9.08). ADDENDUM 19.12.25.: Immunocytochemistry: The neoplastic lymphocytes stain with PAX5. A small number of background lymphocytes are CD3 positive. Control tissues stain appropriately. This result indicates a B-cell immunophenotype lymphoma. 9/1/26: Doxorubicin @30mg/m2 (N: 3.15) - PR- day 7 nadir, N: 6.1223/2/26: Bella presented to ARH for acute deterioration, collapse/generalised weakness, pyrexia (40.7 at presentation) and increased breathing efforts. CRP 349.4. The rest of blood profile largely unremarkable.  USG 1.042, no sign of infection on urine culture, protein 2+. Thoracic radiographs noted extensive infiltrative pattern, not consistent with typical aspiration pneumonia; the infiltrative pattern is similar to thoracic rads taken at diagnosis. - She was hospitalised for intravenous fluid therapy and antibiotics. She received pegylated asparaginase as rescue drug for her LSA.- Her temperature gradually improved overnight. She ate a small amount of food when the family visited the next day and she was discharged on 24/2. Her ambulation have improved slightly though not 100% normal. She remained lethargic25/2/26: phone report at home: she is static though eating more at home. The family have been getting her up every 4-6 hours to the toilet. There has been no vomiting or diarrhoea. Emma reported that Bella was fantastic this morning and she was surprised to come home to Bella moving to another corner of the house to use the toilet. Emma struggled to get her in the car and was distraught that on arrival to ARH, Bella was non ambulatory and she was adamant that the car trip has caused the deterioration.Physical Exam: Weight 40.7BCS 4/9QAR, non ambulatory and wheeled in on the trolleyHR: 140 bpmRR: pantig (increased effort) - mild - harsh lung soundsT: 38.5MMs: Pink, CRT 1-2sSPO2 97% on room airTriaged by criticalist and MSK examination by JDMSK examination: non ambulatory on thoracic limbs, knuckling on the left thoracic limb and paresis of the right thoracic limb; able to stand on pelvic limbs with assistance; no obvious neck pain elicited Ocular: there is a pigmented   5mm mass at the left lower eyelid, not abrading the cornea Aural: NADNasal: NADOral: NAD; extraction sites look fine; tight jaw tone- reluctant to open mouth; no mass noticeable at the left lower lip from previous melanocytic surgery, gag presentCardiovascular: no murmur audible, heart rhythm regular. Femoral pulses strong and synchronous. Respiratory: Lung sounds increased in all fields, particularly during inspiration. Increased abdominal effortAbdomen: distended abdomen, palpable hepatosplenomegaly Integument: 7 x8 mm pink cutaneous mass on right rostral muzzle (FNAB 23/2/26- poorly exfoliative).  good skin coat overall , tick search negative (performed by EM and SC separately). Urogenital: NADRectal: NADLNs today (23/2), all peripheral nodes palpably soft  - static SMLN: L: 1cm, R 1.5cmPrescapular L: 2cm, R 1cmPop 0.5 cm All other peripheral nodes palpably within normal limits Assessment: CURRENT: Bella has developed significant neurological deterioration and was non ambulatory on presentation, which raises spinal cord concern, ddx: spinal lymphoma (Ddx: FCE considered less likely due to gradual progression throughout the week)Multicentric B cell LSA, stage Va with lymphocytosis (cytological diagnosis)- normocalcemic, thoracic rads noted extensive miliary patternCHOP 25 week protocol, commenced 19/12week 1 vincristine @0.7mg/m2 (N: 9.08)  - minimal response - day 7 post vinc N: 4.52, week 2 cyclo @250mg/m2 - minimal response  week 4 doxo @30mg/m2- PR, best response in CHOP-day 7 nadir N: 6.12CURRENT- week 9 CHOP PEGSPAR Dose 1: administered 23/2/26Pertinent:Melanocytic neoplasia of mass on left lower lip surgically removed on 17/09/2025. - MC 2, incomplete margins. Treatment:  Continue prednisolone 30mg PO SIDAmoxyclav 750mg PO BIDMaropitant 80mg PO SID Ondansetron 24mg TM BID-TIDProkolin 8ml PO BID, to stop after 2 days of formed stool If developed ongoing regurgitation, to give metoclopramide 10mg PO TID Prior to each chemo visit:Trazodone 200mg PO to be given 2 hours prior to visit Plan:Continue palliative care with local vet (See comms below)Client Communication: Emma was in distress when she arrived as she was adamant that the car trip has caused the non ambulation and that she should not have brought Bella to ARH. We tried to explain to her that examination in person is required for assessment and help ongoing management plan. Tried to explain that Bella has been unwell since the start of the week and likely has continued to deteriorate. Emma was not convinced, she reported that Bella has done well this morning and that she was hopeful that she could receive chemotherapy today. Emma consented for Bella to be examined in hospital, she does not wished to step foot in the hospital as that will upset her more. Spoke to Dr Angela and updated the situation. Tried to contact Michael but unable to get through. Discussion with specialist surgeon JD and Emma in the front lawn of hospital, explained that the car trip is likely a coincidence and what was bound to happen would likely happen regardless, tried to assure her that at least Bella is at the veterinary hospital and could receive any care required. Explained that there is spinal cord concern, leading to the non ambulation, main differential is likely LSA progressing to her spinal cord. Emma would like Dr Angela to organise euthasia at home. Dr Angela came to ARH and drove Emma, son and Bella home. IVC placed and Dr Angela will orgnanise drugs through her hospital. --- 27/02/2026 17:33:07 RSH:Hello again!  Bella got up & walked when she got home  then she had a big meal of chicken, went outside to do a wee. She got up &  greeted me when I arrived. No euthanasia today but Emma is aware Bella’s time is limited. Would it be possible for you to ok a script for Pred 20mg to be dispensed at WestVets please? I don’t think Bella or Emma will return to ARH. What a roller coaster!!!!Thanks again Email to local vet:Hello team,Hope you are keeping well. We have a mutual patient- Bella Green that we co-managed with Dr Angela.Could you please dispense prednisolone 20mg x 50 tablets on our behalf- 30mg PO SID for ongoing management of her lymphoma. Thank you so much for your help. Kind regards,Rosemary Soh (oncology resident)    Vital Signs    Weight: 40.7;       MMColour: pink ;       Temperature: 38.5;       HeartRate: 140;       RespirationRate: panting;       CRT: 1-2sec;