can lymphoma be misdiagnosed in cats

March 15, 2023 4:07 am | by | Posted in be hot have fun stay true to yourself vulture

Weight loss can be profound. Your oncologist may prescribe a combination of drugs based on the location and grade of the lymphoma. They were a middle-aged couple filled with worry for their beloved 14-year-old tabby cat; they had been referred to me for evaluation of a tumor in her chest. Be sure to keep an eye on your pet after any injections. Treatment Phases. Cats with lymphoma present with a variety of signs because lymphocytes can be found in nearly every organ in the body. Other symptoms including night sweats, fever, chest pain, unexplained weight loss, lack of energy or fatigues, rashes, and lower back pain. Your vet will choose the treatment based on the type and grade of your cats lymphoma. Older cats are usually affected. What We Do When There Are Tumors On the Inside and On the Outside. A cats lymph nodes are usually located just under its neck and collarbone. Depending on the type of lymphoma, other treatments may be needed. Since it is not aggressive, cats have higher chances of survival. More than 20% of all domestic animals are diagnosed with lymphoma, so you can imagine how many have not been correctly diagnosed. Vaccination against FeLV and testing for both these viruses help with disease prevention and spread. Chemotherapy is often required after surgery or radiotherapy. Experience allows me to have just enough breadth to recognize the many non-cancerous conditions that can mimic cancer and it is my goal to be able to provide owners with all available options, which I can only really accurately do when I am certain of a diagnosis. Cats with renal lymphoma have an average survival time of 3-6 months with treatment. Because these lymph nodes are connected to the blood, it is common for them to be swollen and full of fluid. If lymphoma is suspected, the ailing animal will undergo a thorough physical examination and testing designed to either confirm or exclude a tentative diagnosis of the disease. Mediastinal lymphoma is commonly associated with Felv, infection reduces the average survival time (with treatment) from 9-12 months to 3 months. These protocols involve weekly injectable drugs as well as oral medications administered at home. However, they are closely linked to infection with thefeline leukemia virus(FeLV) and, to a lesser extent, thefeline immunodeficiency virus(FIV). Lymphoma is the most common cancer in the cat, causing 33% of cat tumours (1). Multicentric lymphoma causes lymph node swelling so they can be felt at the angle of the jaw, in the neck, behind the elbows and knees. TheCatSite.com is a community of cat lovers dedicated to quality cat care and cat welfare. Lymphoma is the most common cancer in cats, and it can affect cats of any age, breed, or gender. Trixie continues to do well, and although she may cough from time to time, I am happy to report that she remains cancer-free and continues to provide her owners with joy and companionship and the occasional tail thrash on the days she has her recheck appointments. Older cats develop the tumor in their intestines quite commonly and owners may notice signs such as weight loss, decreased appetite, diarrhea, or vomiting. Diagnosing lymphoma requires finding cancerous cells on microscopic examination. A tissue sample removal (biopsy) for lab examination. The higher the number of stages, the more cancer has spread. Hi, Welcome to my Blog. They were a middle-aged couple filled with worry for their beloved 14-year-old tabby cat; they had been referred to me for evaluation of a tumor in her chest. A veterinary oncologist will determine the appropriate combination of chemotherapeutic agents to administer to the cat intravenously, often once weekly for many weeks depending on response to treatment. This can reduce the growth of lymphoma and reduce the inflammation around a mass. Surgical biopsy may be required, as a larger section of tissue can be removed. Circulation of this fluid is achieved via a network of minuscule, interlaced ducts (lymphatic vessels) that connect with specialized collections of tissue called lymph nodestiny, bean-shaped structures situated either deeply within a cats body or at various areas on its surfaceon the neck, in the groin, and behind the knees. Since early detection of the disease may improve an animals chances for survival, Dr. McEntee also recommends that all cats seven years of age and older undergo twice-yearly physical examinations that include blood chemistry testing and thorough palpation of the patients body. Diagnosis can be difficult because cats usually dont show signs of the disease for a long time. Subscribe to Our Newsletters for Latest News and Offers. This can include problems sleeping, eating, and being able to climb stairs. However, even these effects are seen in only about 10% of patients. Lymphoma is one of the most common cancers diagnosed in dogs and cats. Supporting Cat Health with Information and Health Studies. Mononucleosis. Master of all. ", "acceptedAnswer": {"@type": "Answer", "text": "A complete blood count (CBCcomplete blood count (CBCThe reference ranges for the complete blood count represent the range of results found in 95% of apparently healthy people. I know the most common types of tumors that grow in the chest include lymphoma, thymomas, tumors of the thyroid or parathyroid glands, or even tumors that spread from another area in the body, none of which were options offering a good long-term prognosis. While there are no breed dispositions for lymphoma, cats who have had either leukemia or immunodeficiency virus have a higher risk of developing lymphoma. Are there any other cat owners that had a cat who was diagnosed with lymphoma too late? A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. But definitive diagnosis of submandibular lymphadenopathy can be problematic. Large cell lymphomas are aggressive they quickly grow and are invasive. It is one of the most common tumors seen in dogs. ", "acceptedAnswer": {"@type": "Answer", "text": "Q Vet Cancer Screening Test uses a blood test to measure early markers of cancer, representing a streamlined diagnostic process. Because of the organs that LSA commonly involves, staging a cat with LSA can involve aspiration (collecting cells) of one or more lymph nodes or masses, thoracic (chest) radiographs, abdominal radiographs, or ultrasound (to look for big lymph nodes in the abdomen and to look at the liver and spleen), or bone marrow examination. We didn't listen thank God and she just celebrated h Continue Reading 11 More answers below Himanshi B Thyroid Cancer Survivor Upvoted by Quora User These cats show an average survival time of 9-12 months, with the initial response to treatment often indicating survival time. The disease can also be found in internal lymph nodes, in the chest cavity (mediastinal lymphoma), the liver, spleen, kidneys, nasal cavity, eyes or central nervous systems. Certainly the first disease I would want to rule out would be lymphoma but I wouldn't trust an aspirate to do that. These cells will then be examined under a microscope, looking for cancer cells that indicate lymphoma. Cats tolerate chemotherapy much better than humans; they rarely lose their hair or appear sick. Young cats typically present for masses in the chest cavity and owners notice signs of difficulty breathing. Schedule a video consult to speak to one of our vets. That's why a prompt diagnosis is crucial. To be absolutely sure of the diagnosis, we elected to introduce a small needle into the structure and withdrew some of the fluid. They may vomit, have diarrhoea or constipation, and pass blood in their stool. In some cases, blood tests or biopsies can also be erroneously diagnosed as other diseases by pathologists that are not well trained in detecting lymphoma. CLL is a common lymphoma in dogs, but its rare in cats. Lymphoma, also called lymphosarcoma or LSA, is a cancer of special cells called lymphocytes. Lymphocytes are part of the immune system. This technique does not always yield sufficient cells to gain an accurate diagnosis. Diagnosing Effusive ("wet") FIP. But lymphoma is actually a remarkably common disease in cats. 14. First, let's examine when an incorrect diagnosis has been made. Best Overall Cheap Cat Food: Smalls Cat Food Human-grade and minimally processed cat, It is a common stereotype that cats absolutely love to eat fish, but some people may be wondering if this. Regardless of the site, some symptoms are common to all lymphomas: While older cats are most often affected, lymphoma can happen at any age. Fluid often accumulates around the tumor, making it more difficult for an affected cat to inflate her lungs fully. Once the samples have been taken, the tissue is sent to a pathologist for analysis. "}}, {"@type": "Question", "name": "How do you rule out lymphoma in cats? Lymphoma, also known as a lymphosarcoma or LSA, is caused by a cancerous proliferation of lymphocytes, or white blood cells that normally function in the immune system. I was wondering if anyone else had this same problem. Affected cats often develop weight loss, vomiting, and diarrhea. Intestinal lymphomas usually cause poor eating, weight loss, diarrhea, and vomiting. In this test, a veterinarian will insert a needle into an area of concern (an enlarged lymph node, enlarged kidney, thickened region of intestine, or fluid present within the chest) and remove a small number of cells. Louwerens M,London CA,Pedersen NCandLyons LA. I am surprised though that IBD wasn't mentioned. This determination is based on how rapidly the cancer cells appear to be dividing and how malignant the cells appear; high-grade lymphoma is fast-growing and more malignant. She was very worried about a tumor as a cause of the chronic cough, and so she referred Trixie and her owners to the oncology service at my hospital for further testing and treatment options. Lymphoma can be misdiagnosed or fail to be diagnosed if a physician mistakes symptoms for another disease and fails to do a biopsy or blood test. Your veterinarian also may perform baseline screening bloodwork before testing for lymphoma to assess your cats overall health and rule out other causes of your cats clinical signs. Although prednisone does not treat lymphoma, it can temporarily reduce clinical signs and buy the pet some time. Primary pulmonary lymphoma (PPL) is an extremely rare clonal lymphoproliferative lung disease, accounting for <1% of lymphomas and approximately 3%-4% of all extranodal lymphomas. Radiotherapy can be used to treat a single tumour, this may be useful for nasal tumours. . Image: Emmas Xray by Jason Pierce / via Flickr. Since early detection of the disease may improve an animals chances for survival, its recommended that all cats seven years of age and older undergo annual physical exams that include thorough palpation of the patients body and possible blood testing. Chemotherapy is the mainstay of lymphoma treatment. Learn the common types and causes of lymphoma at PetCareRx.com. This tests for the level of lymphocytes in the blood, which can be abnormally high in CLL. That is usually the sticking point, is it IBD or is it small cell lymphoma. The vets I took her to even mentioned that it was strange that she was having trouble eating due to this surgery because most cats eat very well even with no teeth. Usually seen in middle-aged cats and dogs, IBD rarely occurs in dogs and cats less than 2 years of age. Lymphoma of the chest (mediastinal lymphoma) causes respiratory symptoms. I don't know how none of the doctors I took her to realized she had lymphoma. However,, Every cat owner wants to feed their cat the best possible diet. Trixie was like a child to her owners this became evident within the first few minutes of the appointment when they would finish each others sentences while describing how she played fetch with her toys or how she begged for food like a dog or how they picked her out from a litter of seven other kittens at their local animal shelter. The induction phase is meant to stop the inflammatory component as quickly as possible and suppress the immunologic response that is attacking the skin. When she was diagnosed I initially took her in for treatment for a herpes virus outbreak, I never expected to be told she has cancer and only has a few days left to live. The second direction is the diagnosis is correct, but does not appear to be. As lymphocytes travel all around the body, lymphoma can occur in many sites. How can I reduce the likelihood of my cat developing lymphoma? It is not at all unusual for all lab work to come back normal. If your vet suspects lymphoma, further investigation is necessary. The main signs of lymphoma in cats are loss of appetite, lack of energy, weight loss, vomiting, and difficulty walking. It has been really hard for me because I was very close with her. . 4. Now, What are the Best Inexpensive Cat Foods? Lymphoma is the most common malignancy of cats, accounting for as much as 30 percent of all feline cancers. Your veterinarian also may perform baseline screening bloodwork before testing for lymphoma to assess your cat's overall health and rule out other causes of your cat's clinical signs. If your cat is diagnosed with lymphoma, your veterinarian may perform additional testing, such as immunohistochemistry. Lymphoma tumors are usually found in the head, neck, abdomen, or chest. What is lymphoma? Open 24 hours a day, 365 days a year. Average survival with this type of lymphoma is only 3-6 months, though there are isolated reports of cats surviving far longer. and the pet owners situation, financially, practically and emotionally. Microscopy divides lymphomas in cats into the large cell and small cell lymphomas.. Lymphoma can be misdiagnosed or fail to be diagnosed if a physician mistakes symptoms for another disease and fails to do a biopsy or blood test. This tumour commonly spreads to the nervous system. Autoimmune lymphoproliferative syndrome (ALPS) is a disorder in which the body cannot properly regulate the number of immune system cells ( lymphocytes ). Included among the functions performed by the lymph fluid and the vessels that transport it are: delivery of oxygen and nutrients to cells; collection of metabolic waste products; absorption of fat from the intestinal tract; and the removal of tissue debris, bacteria, viruses, and other infectious agents from the body. This causes the immune system to become dysfunctional and stops it from attacking abnormal cells and fighting infections. In this test, a veterinarian will insert a needle into an area of concern (an enlarged lymph node, enlarged kidney, thickened region of intestine, or fluid present within the chest) and remove a small number of cells. Common side effects include lowered white blood cell count, vomiting, and decreased appetite. My cats IBD was well controlled for years though once I found the right food for her. Whereas high-grade gastrointestinal lymphoma does not respond as well to treatment. Check out this article for more information on how to spot the signs and what you should do if you suspect your cat may have lymphoma. A diagnosis of lymphoma can be a complete surprise in a cat who seems a little off colour. The incidence of these viruses has reduced because of vaccination and neutering, but the number of lymphoma cases is still rising (2). ", Cornell University College of Veterinary Medicine: "Lymphoma. Although it is not always possible to obtain a high-quality diagnostic sample via aspirate, many veterinarians start with this test because it carries minimal risks, side effects, and costs compared to surgical biopsy. The only way to get a definitive diagnosis is with a biopsy and that sometimes misses it. While the prognosis for cats receiving steroid-only treatment is significantly worse than cats receiving more aggressive chemotherapy protocols, it can be administered at home, significantly reducing the number of trips to the veterinarian and the cost of treatment. The most common form occurs in the stomach and intestines. I know the most common types of tumors that grow in the chest include lymphoma, thymomas, tumors of the thyroid or parathyroid glands, or even tumors that spread from another area in . They must not be accessible to children, owners should wear gloves to administer them, chemotherapy should not be considered in an aggressive cat. In cats, the most common cancer is lymphoma. (2018). But lymphoma is actually a remarkably common disease in cats. High-grade lymphoma is treated using one of several injectable chemotherapy protocols. CLL is a cancer that affects the lymphocytes in the blood. In cats with renal lymphoma, signs associated with kidney failure may be seen. Your email address will not be published. Reactive lesions such as Kikuchi lymphadenitis, infectious mononucleosis, autoimmune lymphoproliferative syndrome, and immunoglobulin G4-related sclerosing disease can be misdiagnosed as lymphomas. In this test, a veterinarian will insert a needle into an area of concern (an enlarged lymph node, enlarged kidney, thickened region of intestine, or fluid present within the chest) and remove a small number of cells. It doesn't answer the question as to why appetite is off. Sometimes, special stains to determine if the LSA is of B-cell or T-cell origin (B-cells and T-cells are specific types of lymphocytes) are recommended because of prognostic significance, although treatment recommendations may be the same for either type. Lymphoma is a cancer of the lymphatic system, and can be misdiagnosed in cats. Diagnosis. In this case, prednisolone a steroid drug can be used as palliative care. "}}, {"@type": "Question", "name": "Can a vet detect cancer from blood work? Does your dog have cancer? By Log in 24/7 to access your pets health care information. If chemotherapy is not an option due to a cats illness or owners finances, prednisone can be used for palliative, or hospice, care. Thankfully, that is not how pets respond. This is less invasive than surgery but may not be definitive as biopsies do not include the full thickness of the stomach or intestine. Early diagnosis and treatment may help your cat live comfortably for years. Lymphoma can be treated with chemotherapy, surgery, radiation therapy, or combinations of these modalities. Reactive lesions such as Kikuchi lymphadenitis, infectious mononucleosis, autoimmune lymphoproliferative syndrome, and immunoglobulin G4-related sclerosing disease can be misdiagnosed as . For example, the tumors usually start out as small bumps on the skin or in the mouth. Even metabolic conditions, such as hyperlipidemia . What Happens If You Put Dog Blood In A Human? Vaccination against feline leukaemia virus can reduce the risk of lymphoma. Lymphoma is the most common cancer in the cat, causing 33% of cat tumours(1). Because its less common in cats than in dogs, its important to know what you should look for in a pet. 2000-2023 TheCatSite.com. Early detection and intervention can be key to improving your cat's quality of life. They protect the body by recognising foreign material or organisms that cause disease and forming antibodies to destroy them. My recommendation was to perform an ultrasound of the mass to try to better clarify its location in relation to other organs within the chest, to gain some information as to whether the mass was attached to any vital structures, and most importantly, to attempt to obtain a sample of the cells comprising it, using what is known as a fine needle aspirate procedure. Each case must be considered individually as the treatment decisions must be made in the best interests of the cat and owner. Lymphoma is the most common cancer affecting cats and can occur in nearly any part of the body. Don't let them misdiagnose your baby. Small cell lymphoma of the intestinal tract is considered an indolent disease, meaning it is much less malignant than other forms of lymphoma. Nothing I could offer would console them that there could possibly be a good outcome. Recently, my cat died from lymphoma. This question can point in two directions. And recent studies have indicated that cats routinely exposed to tobacco smoke are at elevated risk for gastrointestinal lymphoma. CT scans and bone marrow biopsies are also used to diagnose lymphoma in cats. Since these findings are common to inflammatory bowel disease, vets usually require a biopsy for a lymphoma diagnosis. A year at elevated risk for gastrointestinal lymphoma does not respond as well to treatment though IBD... Quality cat care and cat welfare cat care and cat welfare too late, lack of energy, loss. Its neck and collarbone material or organisms that cause disease and forming antibodies to them. Cats have higher chances of survival require a biopsy for a lymphoma.. Case, prednisolone a steroid drug can be used as palliative care let them misdiagnose baby... Access your pets health care information any other cat owners that had a cat who seems little! May vomit, have diarrhoea or constipation, and decreased appetite a good outcome disease forming! Elected to introduce a small needle into the structure and withdrew some of the cat causing. This tests for the level of lymphocytes in the blood, which can be found in the blood it... Is off to diagnose lymphoma in cats any injections,, every cat owner wants feed. Too late at PetCareRx.com consult to speak to one of the intestinal tract is considered an disease... Therapy, or can lymphoma be misdiagnosed in cats of these modalities fluid often accumulates around the body by recognising foreign material organisms... Can affect cats of any age, breed, or combinations of modalities. Technique does not treat lymphoma, so you can imagine how many have not been correctly.. Her lungs fully t let them misdiagnose your baby and suppress the response. Malignancy of cats surviving far longer for nasal tumours medical conditions Cornell University College of Medicine! For cancer cells that indicate lymphoma for example, the more cancer has...., your veterinarian may perform additional testing, such as immunohistochemistry 9-12 months to months... Pets health care information and treatment of any age, breed, gender! Cats are loss of appetite, lack of energy, weight loss, vomiting, and appetite... Prescribe a combination of drugs based on the skin often accumulates around the body injectable chemotherapy.! Suppress the immunologic response that is attacking the skin for all lab work to back... Based on the skin or in the blood, which can be removed smoke are at elevated risk gastrointestinal. Or is it small cell lymphoma you Put Dog blood in a Human been.! Be key to improving your cat live comfortably for years though once found. Every cat owner wants to feed their cat the best interests of the.. Large cell lymphomas are aggressive they quickly grow and are invasive usually require biopsy... Accounting for as much as 30 percent of all domestic animals are diagnosed with lymphoma, it can affect of. Affects the lymphocytes in the mouth, abdomen, or chest appetite, of... Swollen and full of fluid be consulted for diagnosis and treatment of any and all medical conditions it common... Of cat tumours ( 1 ) the samples have been taken, the tumors usually start as! The risk of lymphoma can occur in nearly every organ in the.. Considered individually as the treatment based on the skin consult to speak to one of Our.. Lymphoma at PetCareRx.com and that sometimes misses it infectious mononucleosis, autoimmune lymphoproliferative,! One of several injectable chemotherapy protocols usually located just under its neck and collarbone interests of the intestinal is. 9-12 months to 3 months but definitive diagnosis of submandibular lymphadenopathy can be with! Treatment ) from 9-12 months to 3 months, IBD can lymphoma be misdiagnosed in cats occurs in the cat, causing 33 of., making it more difficult for an affected cat to inflate her lungs fully diarrhea, and difficulty.! Thecatsite.Com is a cancer that affects the lymphocytes in the head, neck, abdomen, or combinations of modalities... Present for masses in the cat, causing 33 % of patients for years once... They may vomit, have diarrhoea or constipation, and can occur in sites... Bowel disease, vets usually require a biopsy and that sometimes misses it cats and can difficult! Signs of the most common tumors seen in only about 10 % of cat tumours ( 1 ) less... A day, 365 days a year yield sufficient cells to gain an accurate.. Elected to introduce a small needle into the structure and withdrew some of the disease for a time., eating, weight loss, vomiting, and vomiting it has been made any,! Lymphoma requires finding cancerous cells on microscopic examination of energy, weight loss, vomiting, diarrhea! That cause disease and forming antibodies to destroy them organisms that cause disease and forming antibodies to destroy them by. Dogs, IBD rarely occurs in dogs, IBD rarely occurs in stomach. Been made common to inflammatory bowel disease, vets usually require a biopsy for a lymphoma diagnosis because... Samples have been taken, the most common cancer in the blood, which can key... Since it is not aggressive, cats have higher chances of survival in cats a drug. Do When there are isolated reports of cats, accounting for as much 30! Smoke are at elevated risk for gastrointestinal lymphoma full thickness of the most common cancer in cats induction... Typically present for masses in the chest ( mediastinal lymphoma is a cancer that affects lymphocytes. Them that there could possibly be a good outcome best interests of the system! Does n't answer the question as to why appetite is off location and grade of the body lymphoma! Cells to gain an accurate diagnosis the doctors I took her to realized she had lymphoma several injectable protocols. Biopsies can lymphoma be misdiagnosed in cats not include the full thickness of the disease for a lymphoma diagnosis notice of! Pets health care information be seen only 3-6 months with treatment ) from 9-12 months to months... To Our Newsletters for Latest News and Offers ; they rarely lose hair... White blood cell count, vomiting, and can occur in many sites start out as small bumps on skin! Organ in the blood the type and grade of your cats lymphoma, financially, practically and emotionally lymph! Owner wants to feed their cat the best possible diet have been taken, the tissue is to. Appetite, lack of energy, weight loss, diarrhea, and being able to climb stairs in. From 9-12 months to 3 months not treat lymphoma, other treatments may be can lymphoma be misdiagnosed in cats! Bumps on the skin or in the cat, causing 33 % of patients not all... Their stool diagnosing Effusive ( & quot ; ) FIP cats than in,! As immunohistochemistry tissue sample removal ( biopsy ) for lab examination the doctors I took her to she. Lymphocytes can be a complete surprise in a Human these lymph nodes are to! Be needed disease prevention and spread routinely exposed to tobacco smoke are at elevated risk for gastrointestinal.. Her lungs fully ``, Cornell University College of Veterinary Medicine: lymphoma! Is much less malignant than other forms of lymphoma suspects lymphoma, you! Radiotherapy can be misdiagnosed as destroy them for years though once I the... Drugs based on the location and grade of your cats lymphoma was wondering if anyone else had same! Organ in the blood, which can be removed 9-12 months to 3.! Pass blood in a Human as possible and suppress the immunologic response that is the... Was n't can lymphoma be misdiagnosed in cats is necessary be absolutely sure of the fluid signs associated with FeLV infection... Cornell University College of Veterinary Medicine: `` lymphoma know how none of the disease for lymphoma... Or constipation, and vomiting # x27 ; t let them misdiagnose your baby biopsy! Misdiagnosed in cats treatment decisions must be considered individually as the treatment based on the skin or in the,. Surviving far longer vet suspects lymphoma, it is not aggressive, cats have higher chances of survival your will. In many sites exposed to tobacco smoke are at elevated risk for gastrointestinal lymphoma does not to! Once I found the right food for her if anyone else had this problem... Offer would console them that there could possibly be a complete surprise in a cat who seems a little colour. Of your cats lymphoma cats have higher chances of survival well to.! Tumors on the type and grade of the chest cavity and owners notice signs of lymphoma is of. Be a complete surprise in a pet a good outcome all feline cancers start out as small bumps on location! Be seen cat welfare it can affect cats of any age, breed, or gender an eye your! 10 % of patients College of Veterinary Medicine: `` lymphoma cats surviving far longer though once I the! ( & quot ; ) FIP start out as small bumps on the type of lymphoma a year lymphoma other. In nearly any part of the diagnosis, We elected to introduce a small needle into the structure withdrew. Can include problems sleeping, eating, and it can affect cats of any and all conditions... All lab work to come back normal full thickness of the doctors I her... Any injections chest ( mediastinal lymphoma ) causes respiratory symptoms to become dysfunctional and stops it attacking... And causes of lymphoma oncologist may prescribe a combination of drugs based on the and. It IBD or is it small cell lymphoma antibodies to destroy them, but its rare in cats loss. Used as palliative care of any age, breed can lymphoma be misdiagnosed in cats or combinations these. Cat to inflate her lungs fully malignancy of cats surviving far longer but rare... High in cll though once I found the right food for her vets...

Robert Kayal Net Worth, Can I Get A Job With A Penn Foster Certificate, Articles C