St. Francis, Please Protect Margarita

First Treatment Recap and Oncology Visit # 2

Since her first treatment last week, Margarita experienced some vomiting, which we knew was a possible side effect.  Zofran, an anti-nausea medication, was prescribed by our veterinarian for an as-needed basis.  After 2 doses, Rita stopped vomiting initially.  The vomiting continued off-and-on  for a few days.  Luckily this stopped  by March 23rd, a few days before her second treatment.

We also experienced something that was not included on the “what to expect” list. Three nights in a row Margarita released her bladder in the middle of the night while asleep.  She was not aware that she did this, and did not wake up or move when it happened.

Margarita’s appetite is still good – although she is eating very slowly.  We are thrilled that she is still eating all of her meals, as nutrition will be extremely important in helping Rita fight her best battle.

 

March 26, 2019:  Oncology Visit #2

Just in time for her 2nd treatment, Margarita received some extremely thoughtful and supportive gifts this week.

An admirer who is calling on all prayers to heal and protect our little girl sent her a personalized St. Francis of Assisi medal:

 

Our friend, Heather, over at OK Collars sent Margarita a collar! Handmade by Heather, this collar has lime green ribbons on it for Lymphoma Awareness.
Margarita wore her Lymphoma collar and her St. Francis of Assisi medal to her appointment today.
The appointment:
Our oncologist, Dr. Risbon, said Rita’s exam was overall normal, and Rita gained weight (0.2 kg / or about 0.44 lb).   A blood test taken, and Rita’s CBC was acceptable for continued therapy. However her tests showed her to be a bit more anemic today.
Dr. Risbon said the vomiting Rita experienced could be a side effect but she did not seem concerned. Dr. Risbon also did not seem to worried about the bladder issues Rita.  She told us that some of the treatments (including this week’s medication) can cause some irritation to the bladder (called sterile hemorrhagic cystitis).  This week especially, we will have to monitor Rita for straining during urination, urinating small amounts frequently, incontinence, or blood in her urine.

Margarita in the exam room at VSEC

 

Treatment #2:
This treatment will be administered by us at home over the next few days.
  • Cyclophosphamide 40 mg
    • 2 tabs by mouth 3/26 and 3/27, then 1 tab by mouth on 3/28
      • Wear gloves when administering.  Do not split/crush tablets
  • Prednisone
    • 10 mg once a day until next treatment

 

After her oncology visit, Margarita got her favorite treat at Starbuck’s… a Puppuccino !

Another thoughtful and handmade gift was presented to us just in time for the start of Rita’s 2nd treatment.  Brian came home from work with a handmade recovery blanket made by Jess – a wonderful woman who works with Brian!
The inside of this beautiful quilt is lined with super-soft material  – perfect for Rita to snuggle in after her treatments!
Rita wrapped in her recovery blanket after the start of her 2nd treatment.
Margarita will have her another oncology appointment next week.
Thank you for joining Margarita in her journey to take a bite out Lymphoma.

 

Chemotherapy: What to Expect

Approximately 10-20% of veterinary oncology patients experience side effect after chemotherapy including:

  • loss of appetite
  • vomiting
  • diarrhea (generally 3-5 days after therapy)
  • drop in white blood cell count (generally 7 days after therapy)

Most of the time these signs are mild and self-limiting and resolve with supportive care (bland diet, anti-nausea / anti-diarrheal medication) at home.  Less than 5% or patients require hospitalization after treatment.

Below are the instructions and possible side effects of steroids and chemotherapy that we received from our Oncologist, Dr. Risbon, at  VSEC.

Steroids

Prednisone may cause the following side effects:

  • excessive thirst
  • urination
  • panting
  • increased appetite

Other rare but possible side effects include:

  • loss of appetite
  • vomiting
  • diarrhea
  • dark/tarry or black stools

****If your dog experiences any of the above rare side effects, you should call your primary veterinarian or your oncologist immediately.

Other very important things to note:

  • Steroids cannot be given with non-steroidal anti-inflammaroty medications (NSAIDs) such as Rimadyl (Carprofen), aspirin, Deramaxx, Metacam, Piroxicam, and other drugs in this class.
  • Once started, steroids cannot be stopped suddenly as this can be detrimental to your dog.  You must speak with your primary veterinarian or your oncologist for appropriate instructions on weaning your dog from this medication.

Chemo therapy instructions

Do not give the chemo if your dog is not feeling well. For example: vomiting, diarrhea, very lethargic, not eating, etc. Contact your oncologist before you begin/continue oral medication to receive further instructions.

Handling instructions for chemo

Wear latex gloves while handling chemo drugs. Dispose of the gloves into a garbage bag, tie the bag, and wash your hands. If you come in contact with the chemo drugs wash your hands thoroughly. Children and pregnant or nursing mothers should not handle chemo. Keep chemo in an isolated place, out of the reach of children and animals, and away from where other medications or food are stored.

Waste

A small percentage of chemo may be excreted in the urine and stool for the first two days after treatment. If your dog has an accident in the home wear latex gloves and discard in a garbage bag. Clean the area thoroughly with a regular cleaner and try to cover or avoid carpeted areas for 48 hours after cleaning. For waste outside, you should try to avoid the area for 48 hours or spray the area with water. If you are walking your dog on public property, bring a bottle of water and soak the area.

Side Effects

Vomiting/nausea

If your dog is vomiting, it may be due to the side effects from the chemo therapy or the cancer itself. If you have anti-nausea medication, you should start it at the first sign of vomiting. If you do not have this medication call for a prescription. Most of these medications can be called into your local pharmacy. If your pet vomits shortly after this medication is given (for example less than 15 minutes), the medication may not have been absorbed. It may be necessary for your pet to receive an injectable anti-nausea medication. Do not give any over-the-counter medications until approved by your doctor.

  • If your dog vomits more than 3 to 4 times in a couple of hours or vomits after every meal, take up all food and water for at least four hours. It will help in emptying their stomach of any contents while reducing the catalyst to vomit.
  • If vomiting continues call your primary veterinarian, or your oncologist
  • If vomiting stops after four hours of fasting, offer small amounts of water. This will help determine if your pet can hold anything in the stomach without vomiting. If your pet does not want to drink water, consider trying alternate fluids, such as broths, Pedialyte, apple juice, etc. If vomiting continues, you should contact your primary veterinarian or your oncologist for further instructions.
  • After several hourly trials of offering water with no vomiting you can try to offer small amounts, enough for only a couple of bites, of bland food. For example baby food, chicken and rice, etc. every three hours. If there is no vomiting continue to offer food. Slowly increase the amount offered each time.

****If you notice any blood in the vomit, notify your oncologist or your primary veterinarian immediately.

Diarrhea/Constipation

If your dog has diarrhea, it may be due to certain G.I. cancers, chemotherapy given previously, the body’s malabsorption of fluids, suppressed immune system, diet, or intestinal motility changes, among other possibilities.

Temporarily switch from your dog’s normal diet to a bland diet of boiled rice/pasta/potatoes and boil chicken or boiled hamburger. Keep your dog hydrated and make sure that water is readily available.

  • Continue this diet until the diarrhea has stopped for at least two days. You will then slowly mix back in your dog’s normal diet with a bland diet.
  • If diarrhea continues for two days while on this diet please contact your oncologist or your primary veterinarian for further instructions. An anti-diarrheal medication may be prescribed, as well as fluid therapy and a chem/electrolyte panel.

For constipation, consider giving canned pumpkin or Metamucil. Be sure to call your primary veterinarian or your oncologist for the correct dosage of Metamucil for your dog. Your dog may need to be seen if there is no defecation within a period of 48 hours. Do not give any over-the-counter medications until approved by your oncologist or primary veterinarian.

****If you notice black/tarry stools or the presence of blood, notify your oncologist or your primary veterinarian immediately.

Anorexia/poor appetite

If your dog experience has a poor appetite, it may be due to nausea from the chemo, the cancer itself, picky tastes, a pre-existing poor appetite, chemo related scent changes, among other possibilities. Try introducing other food choices, such as

  • Baby food or canned dog/cat food
  • Different brand of food, boiled chicken or hamburger mixed in with regular diet, roasted chicken, steak, fish, or cooked eggs
  • Flavor stimulants such as pet gravy from pet stores, or low-sodium broth
  • Warm soft foods, or add warm water to dry foods. This can bring out the flavor and aroma
  • Cottage cheese or plain yogurt, alone or mixed in with the regular diet
  • Try hand feeding or syringe feeding. Put food into the blender if syringe feeding

If you have any anti-nausea medication start the medication since poor appetite could be due to nausea. If your dog does not eat beyond two days, or if you are concerned, contact your oncologist or your primary veterinarian for further instructions. Certain medications may be dispensed to stimulate the appetite.

Lethargy/weakness/fever

If your dog experiences lethargy, weakness, or fever it may be due to the chemotherapy given, the bodies adjustment to the new chemo drug in the system, the cancer, among other possibilities. Usually this only last for a few days. Your dog may not act like him/herself, may exhibit behaviors not noticed before, and may not be feeling well. In response to this you should keep an eye on your dog for these things and notify your oncologist and or primary veterinarian if it progresses for an extended time or if you are concerned.

In addition take your dog’s temperature rectally with a digital thermometer, and use Vaseline or KY jelly for lubrication. Normal temperature range for dogs is from 100.5° to 102.5°. A temperature above 103.5° should be reported to your oncologist and primary veterinarian.

The Sixteen-Week Plan: PAWsitive Vibes Only

March 19, 2019

Margarita is a very special and complex case considering she has significant liver and intestinal diseases.  This does not allow us to deviate from her special diet, and limits some of our options. After much discussion with our primary veterinarian, Dr. Campbell, (who I would trust with my own life – they just don’t make women/people/doctors like her anymore!!) we have decided that Rita’s best chance of survival is to undergo at least one round of chemotherapy – IF her compromised system can handle the complete round.

We met Margarita’s oncologist, Dr. Rebecca Risbon, at Veterinary Specialty and Emergency Center (VSEC).

Based on the tests, Dr. Risbon explained that Margarita has been diagnosed with Stage IV A Lymphoma. Since her bone marrow was not tested, we are unsure if the cancer is present in her bone marrow. Chemotherapy is suggested because of this.  The staging chart is below, with Rita’s stages in bold.

Stages:

  • Stage I:  Cancer involving one lymph node
  • Stage II: Cancer involving more than one lymph node but on one side of the diaphragm
  • Stage III: Generalized lymph node involvement
  • Stage IV:  Spleen or liver involvement, with or without the previous stages
  • Stage V:  Bone marrow involvement

Substages:

  • Substage A: Absence of clinical signs of illness
  • Substage B:  Presence of clinical signs of illness

The good news is that Rita has a couple of prognostic factors in her favor.

  • Her cancer is B Cell (T Cell is even more aggressive than B Cell)
  • She is not Stage V
  • She is Substage A
  • Her calcium is normal

Without further treatment beyond the Prednisone she was on, Rita’s survival time would be about 1-2 months.  If we began chemotherapy, Rita has a chance of surviving approximately 12-18 months.  There was no question that we were opting for the chemotherapy.

With Rita’s Stage of Lymphoma, research has determined that the best results have been achieved with protocols that combine the 4 most effective agents against lymphoma:  Vincristine, Cyclophosphamide, Doxorubicin (Adriamycin), and prednisone.  This is referred to as CHOP-based protocols).  In most cases, the CHOP-based protocol used on dogs with Stage IIIA or IVa Stage Lymphoma produces an 80-90% remission rate, an average disease-free interval (1st remission) of 9 months, a median survival rate of 12 months, and a 20-25% survival to 2 years.

Margarita’s chemotherapy plan is 16 weeks.  The hope is that her liver and intestinal issues are not going to hinder this plan’s completion.

She will be seen on a weekly basis so that she may be evaluated for improvement and toleration of the treatment itself.

Today Margarita received the following:

  • L-asparaginase @ 400IU/kg
  • Vincristine @0.5mg/m2 IV
  • Prednisone @ 2mg/kg PO/day until next week’s visit

Due to Margarita’s other health issues, Dr. Risbon recommended keeping Rita on the prescription GI diet.  She also recommended to add fish oil back into her diet.  Dr. Risbon told us that fish oil as a supplement has been shown to improve survival times slightly in dogs with Lymphoma.

I promised Rita that we would do something special each week right before or right after her treatments.

This week she got to enjoy a couple of McDonald’s fries!

(Don’t worry – she only had a couple!)

Margarita is scheduled for her second visit with Dr. Risbon next week.

Image result for cancer bites with a green ribbon

Thank you for joining Margarita in her journey to take a bite out Lymphoma.

How We Discovered Rita’s Lymphoma

One evening this past January, we went to bed not knowing we would wake up to what would lead us to later “accidentally” discover that our Margarita has Lymphoma.

January 7, 2019

In the middle of the night, on January 7th, Margarita jumped-up out of a sound sleep and hopped off our bed.  She went to the bedroom door and proceeded to urinate on the floor.  This was not like her at all.  We questioned ourselves – “Did we forget to let her out before bed?” We took her out into the yard, and watched her urinate several times… “Must be a urinary tract infection!” we said.  We also observed that she seemed a bit out of sorts, and just stared off in to the empty yard.  The next morning though, she seemed fine, and was not urinating more than normal, so we did not think a call to our veterinarian was necessary.  The next night, we were woken up once again by the sound of Rita frantically jumping up and running for the bedroom door.  This time, she defecated on the floor!  We didn’t know WHAT to think at this point.  You may be reading this thinking – “What’s the big deal?” – dogs have accidents, end of story.  NOT this dog, and NOT in the middle of the night.  Rita lives for her beauty rest.  Rita does not EVER get up in the middle of the night, other than to switch sleeping positions.  By the end of the night on Tuesday, January 8 and into the morning on Wednesday, January 9, Margarita again began to urinate very frequently – much like the symptoms of a urinary infection.  She also seemed lethargic, and less interested in food (DEFINITELY not like Rita at all).  Wednesday morning we called our veterinarian, Dr. Campbell, and made an appointment for that night.

January 9, 2019

I drove Margarita to the vet on Wednesday evening expecting for a quick appointment with Dr. Campbell telling me that Rita had a urinary tract infection.  A urinalysis was conducted at the visit – and Rita did, in fact, have blood in her urine, and was given Cephalexin.  Margarita’s gums were also very pale and tacky, and her temperature was low.  Margarita was screened for tick-borne diseases, and this was negative. When I began describing other some of the other unusual-for Margarita-behaviors, Dr. Campbell asked if I would be OK with her doing a quick ultrasound on Rita.

When Dr. Campbell returned to the exam room with Rita, I could tell by her face I was not going to like the news of her findings. What was seen on the ultrasound was what looked to be a mass on her spleen.  A full panel of bloodwork was done on Rita.

  • CBC / Blood Smear In-House
  • IDEXX Total Health

The bloodwork results showed that her liver values were elevated, and that she was anemic.  Dr. Campbell immediately referred us to get an ultrasound with a specialist at Veterinary Specialty and Emergency Center (VSEC).

During this time, I had elected to put Margarita on “temporary retirement” from visiting my school as the District Therapy Dog.  I had not given any of the details to the students, but I did tell them she was not feeling well.  One of my very thoughtful students brought in a gift for her.  Inside the bag was a bone and sweet get-well note.

Margarita enjoyed her treat when I went home for lunch that day.

January 10, 2019

Rita was seen for the ultrasound at VSEC on January 10th, where a full abdominal ultrasound was done by Dr. Ana Caceres.  A splenic mass measuring approximately 2.5 cm in diameter was seen, but Dr. Caceres felt like the mass was unlikely to be the primary cause of Rita’s symptoms.  Dr. Caceres recommended that we pursue further evaluation regarding her urinary tract.  The following test were done in addition to the ultrasound:

Dr. Caceres referred to see an Internal Medicine doctor.

 

January 12, 2019

Dr. Campbell, our primary vet, did chest x-rays on Rita, which thankfully came back clear.

January 16, 2019

Margarita saw the head of the Internal Medicine Department at VSEC, Dr. Alan Klag. Dr. Klag did an exam and ran some blood work and took a sterile urine sample.  Although a recent urine culture taken at our primary veterinarian’s office was positive for Staphylococcus pseudintermedius, Dr. Klag did not expect that to cause the current clinical signs unless the infection was in her kidneys – but even then he would not expect the anemia, hypoalbuminemia, and increased  ALT that were present in her bloodwork.   Dr. Klag ran the following tests:

  • PCV/TS
  • Mini Liver Panel

Dr. Klag decided to treat the urinary tract infection with Enrofloxacin .  Dr. Klag suggested that considering the other symptoms we are observing, Rita could be experiencing some small repeated bleeding incidents from her splenic mass. It was suggested that we consult with a surgeon to discuss the biopsy of the splenic mass and/or a possible splenectomy.

January 25, 2019

Margarita had some more blood work done with Dr. Campbell to re-check her liver levels.

  • IDEXX Catalyst Chem 10 CLIP
  • PCV (Packed Cell Volume) / TS
  • IDEXX CBC, Comprehensive

January 30, 2019

We were still observing a bloody discharge from Rita’s rear-end.  Because of this, several stool samples were sent out to Texas for a Fecal Alpha Proteinase Inhibitor test .  The concern was that Rita had a GI disease where proteins could be lost into the gastrointestinal lumen.  Gastrointestinal protein loss can be associated with a variety of gastrointestinal and systemic disorders such as:

  • idiopathic inflammatory gastroenteropathies
  • gastrointestinal neoplasia
  • foreign bodies
  • intussusceptions
  • small intestinal bacterial overgrowth (SIBO)
  • infectious enteritis
  • immune-mediated diseases
  • intestinal lymphangiectasia.

Margarita’s fecal tests came back negative.

February 14, 2019

Margarita was still exhibiting the same symptoms, and saw the surgeon on February 14th.  We met with Dr. Jennifer MacLeod to discuss Margarita’s case.  Dr. MacLeod felt that it was unlikely that the splenic mass was malignant. However, both benign and malignant splenic masses can appear identical on ultrasound, x-rays and even during surgery.  The only way to accurately diagnose the type of mass is with a biopsy.

Dr. MacLeod also felt as though there was a low chance of the mass rupturing, but because this can be very unpredictable, it should still be considered a risk. Both benign and malignant masses can rupture and bleed into the abdomen, which is a life-threatening condition that requires emergency surgery.

Margarita’s lethargy was still a bit of a mystery.  Dr. MacLeod felt that a liver biopsy may provide a cause for her increased liver enzymes, which could be related to her lethargy.

Due to the clinical changes and the splenic mass, Dr. MacLeod recommended exploratory surgery to remove the spleen, and do biopsies of Rita’s liver, and intestines in order to obtain a more definitive diagnosis.

February 21, 2019

Margarita had her surgery and biopsies.

The day Margarita went to the hospital for her surgery, a friend of ours sent her a Get-Well-Soon package from Chewy.com!

I could not believe this HUGE package of goodies for Rita!

Margarita had to stay the night at VSEC for monitoring, and was able to come home the next day.

February 22, 2019

On her way home from surgery:

Settling in at home after surgery:

Margarita had some difficulties the first few days, but overall, recovered well, and in about 2 weeks seemed more like herself again.

We set up a special “recovery room” so that our other fur-kids would not bother Rita while she was healing.

During her recovery she received gifts, flowers, and well wishes from so many people!

We were overwhelmed with the support, concern, and love our baby received.

Margarita with her card and gift from our neighbor:

Margarita’s “main-man” Mr. Spock the English Pointer sent her a beautiful bouquet of flowers:

 

February 27, 2019

On the morning of February 27th, we received the news that no one ever wants to hear.. there were malignant cells found in Rita’s spleen.  They were round cells, which indicated a type of Lymphoma. Additional tests would have to be run on the biopsies to identify what kind of Lymphoma it was.  But that wasn’t all.

Although malignant cells were not found in Margarita’s liver and intestines, she also had concerning diseases in both.  Her liver showed inflammation patterns that represented chronic hepatitis.  Despite her prior negative Fecal Alpha Proteinase Inhibitor test, her intestinal biopsy showed a severe degree of inflammatory bowel disease, causing the loss of proteins.  Without these two significant issues under control, Margarita would not be able to handle cancer treatment, if needed. Margarita was put on steroids, and her diet was changed to a GI-specific diet. The symptoms we had been seeing in Rita were not necessarily from the cancer itself – so we were very lucky in a way to have discovered ALL of this before it was too late.

We ordered the additional immunohistochemistry, for all previous biopsies, and anxiously awaited the results.

March 13, 2019

The detailed results and diagnosis came back to us in the afternoon on March 13th.  It was then that we found out Rita has Diffuse Large B Cell Lymphoma. We also learned her lymph node, liver, and intestinal biopsies thankfully did not show signs of the cancer spreading at this time to those areas specifically.  Unfortunately, even after malignant tissue is removed, the cancer may have already spread microscopically to other areas.  Since the cancer was detected in the spleen, which filters the blood, there is a concern that the cancer could now be present in her blood and bone marrow.

Dr. Campbell referred us to see the oncologist at VSEC.

 

 

 

Mini Carrot Cakes

 

Ingredients:

  • 1 cup organic whole wheat flour
  • 1 tsp organic ground cinnamon
  • 1/2 tsp organic ground ginger
  • 1  1/2 cups organic grated carrot
  • 2 organic eggs
  • 1 Tbsp water
  • 1/4 cup organic extra virgin olive oil
  • 3/4 c organic unsweetened apple sauce

Instructions:

  • Preheat oven to 350°F
  • In a large bowl, whisk together the flour, cinnamon, and ginger
  • Stir in the grated carrots, and combine until the carrots are coated with the flour mixture and are not longer clumped.
  • In a separate medium bowl, beat the eggs
  • Next, stir in the eggs, water, olive oil, and applesauce
  • Make a well in the center of the flour mixture and add the applesauce mixture.
  • Stir all ingredients until thoroughly combined.
  • Spray a mini muffin tray with organic non-stick cooking spray
  • Pour the cake batter into the cupcake tray.
  • Bake for 20-25 minutes, or until a toothpick inserted in the center comes out clean.

**Optional:  When cupcakes are completely cooled, top with Cauliflower Cream Cheese Icing

This recipe can also be used to make an 8-inch round cake.

 

Recipe modified from Dog Cakes: Recipes for Every Occasion