Recap of Month 8 of Remission
Since her last monthly check-up, Margarita had another remarkable month. She visited my school again, and made some students extremely happy!
The weeks that followed this classroom visit, however, have been an emotional rollercoaster ride.
Monthly Check-Up with Oncologist
On December 6, 2019, Margarita saw her oncologist, Dr. Risbon, for her recheck for lymphoma. During her appointment, I noticed that Margarita was drooling slightly while she was with the doctor, but I didn’t think much of it at the time. Her physical exam was normal and there was no evidence to suggest recurrence of lymphoma. Doctor Risbon could not hear her heart murmur on this day, and Rita’s heart rhythm was reported as normal. Dr. Risbon evaluated Rita’s mammary mass and shared that the thickened tissue portion was similar, and the mass that she could feel seems to have had no change from previously. Dr. Risbon also confirmed that she felt the new small nodule noted by Dr. Campbell during her last visit. Dr. Risbon was pleased with Margarita’s progress and deemed her to be about 9 months in remission. I was very grateful for this good report, but sad and fearful at the same time. This was Margarita’s last appointment with this oncologist, as Dr. Risbon is going on maternity leave, and then transferring to a facility that is out of driving range to our home. Dr. Risbon assured me that the new oncologist will take great care of Margarita, and also told me I could reach out to her at any time with questions on any new findings. We are very thankful to Dr. Risbon for seeing Margarita through her chemotherapy, and wish her the best while adding to her family and continuing her practice at a new location.
Monthly Check-Up with Primary Veterinarian
On December 9, 2019 Margarita had a visit with our primary veterinarian, Dr. Campbell. This visit was her monthly check up, as well as her yearly therapy dog examination. In addition, this appointment was also for bloodwork that Rita’s cardiologist, Dr. Bossbaly, requested at Rita’s last visit to test her kidney function because of the heart medication she is currently taking. Dr. Campbell examined Rita’s mammary tumors and reported that they have not changed since last visit. When Dr. Campbell asked me how I thought Rita was doing, I shared that her appetite and energy were both great. I also explained that I noticed Rita drooling slightly at her oncology appointment, and that was something I had never observed before. I almost didn’t even bring it up – but so thankful now that I did. Dr. Campbell then looked at Rita’s gums and said that they didn’t look super pale, but she just wasn’t 100% happy with the color she saw. Dr. Campbell suggested we do some additional blood work beyond the tests Dr. Bossbaly requested for kidney function. I didn’t worry too much about Rita’s gum coloring, and honestly didn’t expect much to come of the bloodwork that Dr. Campbell sent off for testing.
On December 10, 2019 Dr. Campbell called us with the bloodwork results. Much to our dismay, Margarita’s liver values were through the roof. Dr. Campbell explained that the drooling could likely be caused from nausea if something was abnormal in her biliary tract. Rita’s liver values are below:
- ALT Normal range: 18-121
- Rita’s ALT value: 1,155
- GGT Normal range: 0-13
- Rita’s GGT value: 22
- AST Normal range: 16-55
- Rita’s AST value: 146
- ALP Normal range: 5-160
- Rita’s ALP value: 447
Dr. Campbell had us schedule the first appointment we could secure with Chief of Diagnostic imaging, Dr. Alexander “Sandy” MacLeod at VSEC. The first available we could schedule was December 19, 2019. Brian and I were nervous to wait that long, so Dr. Campbell had me bring Margarita to her office that evening to do a brief abdominal ultrasound. Dr. Campbell observed that Rita’s liver and gallbladder were somewhat enlarged. She shared that this may be cholestasis caused by the “backing up” of chemo drugs. She started Rita on a low dose (125mg once daily) of Ursodiol in hopes that we’d see a marked difference at the time of her abdominal ultrasound at VSEC.
Abdominal Ultrasound with Dr. MacLeod
If you have been following Rita’s Lymphoma Journey from the beginning, you may be thinking that “Dr. Macleod” sounds familiar. That’s because Dr. Alexander “Sandy” MacLeod’s wife, Dr. Jennifer MacLeod is the doctor who performed Rita’s splenectomy.
Dr. Sandy MacLeod performed an abdominal ultrasound on December 19, 2019. Despite the Ursodiol Margarita was taking, there had been no difference in Rita’s condition. His findings were as follows:
- Liver: Hypoechoic, mildly enlarged. 1-2 cm hypoechoic nodule in ventral left medial lobe
- Gallbladder and Biliary Tree: Gallbladder moderately dilated with anechoic bile, no wall thickening or duct dilation
- Spleen: absent
- Kidneys: no abnormalities identified
- Arenal glands: no abnormalities identified
- Uriniary bladder: no abnormalities identified
- Stomach: Mild thickening of pyloric wall. Mild fluid dilation of pyloric antrum
- Intestines: no abnormalities identified
- Colon: no abnormalities identified
- Pancreas: no abnormalities identified
- Peritoneum: no abnormalities identified
- Mesentery: no abnormalities identified
- Lymph Nodes: no abnormalities identified
Diagnosis and Recommendations:
Although I was thrilled that her lymph nodes were normal, I was devastated to hear the word “nodule.” Dr. MacLeod explained that the liver findings could be due to hepatitis , toxic insult, infiltration (recurrence of lymphoma) or other hepatopathy. Dr. MacLeod was most concerned that the findings could be the Lymphoma reappearing with a new disguise, so he recommended a guided needle aspirate of the liver nodule and its surrounding tissue for cytologic analysis, which was done during that same appointment. Dr. MacLeod shared that the mild stomach thickening and dilation is most consistent with gastritis.
We received a call from Dr. MacLeod on December 21, 2019. The first thing Dr. MacLeod said was “It’s not Lymphoma.” To say we were relieved was an understatement – hearing this was THE best Christmas gift ever! BUT…what WAS causing the high liver values, enlarged liver , thickening of the stomach, and enlarged gal bladder? This remains unknown. Dr. MacLeod suggested that we do the same bloodwork again with Dr. Campbell to compare Margarita’s liver values in a few more days to see if they corrected themselves now that Rita has been on Ursodiol for a longer period of time. He added that if the liver values do not improve, it would be time to see an Internal Medicine Specialist.
On the morning of December 26, 2019 I took Rita to or primary veterinarian’s office. Dr. Campbell drew Margarita’s blood, and sent the sample out to the lab. Later that evening, Dr. Campbell called us with the results. Margarita’s liver values had increased yet again, despite the Ursodiol she had been taking. The results are below:
- ALT Normal Range: 18-121
- Rita’s ALT Values:
- 1,155 (12/9)
- 1,195 (12/26)
- Rita’s ALT Values:
- GGT Normal Range: 0-13
- Rita’s GGT Values:
- 22 (12/9)
- 22 (12/26)
- Rita’s GGT Values:
- AST Normal Range: 16-55
- Rita’s AST Values:
- 146 (12/9)
- 146 (12/26)
- Rita’s AST Values:
- ALP Normal Range: 6-160
- Rita’s ALP Values:
- 447 (12/9)
- 569 (12/26)
- Rita’s ALP Values:
These were obviously not the results we were hoping for. Dr. Campbell directed us to stop the Ursodiol and suggested we make the first available appointment with Dr. Klag , the Chief of Internal Medicine at VSEC. Dr. Klag is the Doctor that first saw Margarita in January 2019. Margarita has an appointment set with Dr. Klag for January 16, 2020 (his first available). I also requested to be put on a cancelation list in hopes of getting a sooner appointment. However I was told they do not do a waiting/cancelation list for the Internal Medicine department. I explained that we have been put on a waiting/cancellation list at VSEC in the past for other doctors and departments – such as Dr. Bossbaly in the Cardiology department. I expressed my frustration and disappointment to the staff member making the appointment. The woman I was speaking to informed me that Dr. Klag would return to the office from his Holiday Break on January 2nd. Additionally, I sent an email directly to Dr. Klag to inform him of the events and multiple diagnoses that have taken place since he last saw Margarita in order to explain the urgency behind our request for a sooner appointment. Lastly, I will be calling VSEC 2-3 times a day leading up to the scheduled appointment in hopes of catching a cancellation that would otherwise go unannounced due to the department’s lack of waiting list.
Although these past few weeks have been an emotional roller coaster for us, I am grateful for every single day that Rita is still riding. Brian and I entered the front seat of this roller coaster prepared for the peaks of celebrations, the abrupt falls, and the mysterious turns Lymphoma would throw at us. Positivity and vigilance are key. Although it is a scary ride, I will be keeping my eyes wide open. Had I neglected to mention that little bit of drool to Dr. Campbell, Rita’s roller coaster could have spun out of our control before we knew what hit us. I am embracing the highs and lows of this scary ride. I celebrate and appreciate each peak – and I’m accepting the plummeting falls as more knowledge that I hope will not only help Rita continue to take a bite out of Lymphoma, but also assist other pups and PAWrents in the future.
Keep those prayers coming – and buckle up – we may be in for a rough ride ahead.
This Month’s Treat
Following her monthly appointments, Margarita enjoyed a small portion of a beef and cheese quesadilla from Wawa.