January | 2020 | Cello's Corner

Month 9 Remission Recap

I have to admit, at first I thought this past month was a bit of a let-down – that the elevated liver enzyme result discovered last month was a set-back for Margarita. I found myself losing a bit of hope – until I spoke to a friend who asked how Margarita was doing. When I explained to my friend what you will soon read in this month’s post, I quickly realized just how grateful I should be. Speaking with my friend reminded me just how lucky we are, as my friend had recently lost multiple 2-legged and 4-legged family members to cancer – all within a short time frame of each other. All of those family members lost their battle with cancer in much less time than Rita has been in remission. In addition, Margarita’s new oncologist instilled even more appreciation in my heart. This past month wasn’t a setback for Margarita at all … it was just a setup for an even greater comeback, as well as a reminder for me to put some gratitude in my attitude and celebrate each and every day!

This past month Margarita visited Chimney Rustic Ales , had fun playing in the yard, and enjoyed destroying stuffies in the house on rainy days.

Margarita also visited my school twice this month, bringing joy to both children and adults.

Internal Medicine Evaluation

Now just a little over a year from her first Internal Medicine evaluation, Margarita was seen by Dr. Peter Chapman in VSEC’s Internal Medicine Department on January 15, 2020.

After careful review of Margarita’s case, Dr. Chapman explained that he believes Rita’s elevated liver values are most likely caused by one of the following:

Chronic Hepatitis (most likely given the previous biopsy)
Lymphoma (less likely given the fact that she is doing well)

Dr. Chapmans shared that other less-likely causes of the elevated liver enzymes are as follows:

Copper Hepatopathy
Infection
Toxic insult

Dr. Chapman explained there are a couple of ways we could try to determine which of the above was causing Margarita’s elevated liver values:

empirical treatment
1. Prednisone
  - This medication can help with liver disease
  - This medication also battles Lymphoma so it could help with Lymphoma – but would also mask that the disease is the culprit leading to other issues
2. Cyclosporine
  - This medication has potential to prompt the Lymphoma to come out of remission
laparoscopic surgery for liver biopsy to gain definitive diagnosis
- There is concern that even though this procedure would be less invasive than her splenectomy, this would still be a difficult procedure for Rita to endure so soon after everything she has been through in the past year, and given her liver and intestinal diseases
- There is concern for anesthetic risk with Rita having chemotherapy-induced Dilated Cardiomyopathy
- If this route is chosen, Dr. Chapman also noted that he would opt not to remove Margarita’s two mammary masses during this procedure due to the prolonged anesthesia creating a greater risk

Dr. Chapman also did a blood test while we were at this appointment and submitted a mini liver panel to see if Rita’s liver ALT value was still elevated. The test revealed the following:

ALT Normal Range: 18-121

Rita’s ALT Values:
1. 1,155 (12/9/19)
2. 1,195 (12/26/19)
3. 924 (1/15/20)
  - Even though her ALT number dropped, 924 is still very elevated considering the normal ALT range is 18-21

ALP Normal Range: 6-160

Rita’s ALP Values:
1. 447 (12/9/19)
2. 569 (12/26/19)
3. 444 (1/15/20)
  - Even though her ALP number dropped, 444 is still very elevated considering the normal ALP range is 6-160

Now to do our best to make the most appropriate decision for Rita….

Patiently waiting in the sitting area of VSEC for her appointment

A Difficult Decision

Although nothing about Margarita’s Lymphoma Journey has been easy, we were not expecting such a difficult decision in choosing which option is in Margarita’s best interest. After much thought and long discussions with Margarita’s medical team, we have decided to treat Margarita with Prednisone and Denamarin. Denamarin is a nutritional supplement containing the antioxidant Silybin used to improve liver function by increasing liver glutathione levels.

Dosages are as follows:

Prednisone:
- 5 mg twice daily
Denamarin:
- 1 tablet daily

It was easy to decide Cyclosporine is completely off the table since it has the tendency to bring Lymphoma out of remission. That part of the decision was a no-brainer.

We immediately wanted to know if Rita’s lymphoma has returned, as we are well aware that chemotherapy knocks the disease down, but does not completely rid her body of the cancerous cells. We knew that since the lymphoma originated in her spleen, the return of this disease could be difficult – and maybe even impossible – to catch in time. Although we feel the need to know if the Lymphoma is resurfacing, we don’t want our strong desire for clarification to override what is best for Margarita. Her needle biopsy with Dr. MacLeod was negative. Although the needle biopsies are sometimes not as precise as the full biopsy that laparoscopic surgery can provide, we are praying it was accurate. Putting Rita through another surgery will be a last-resort option.

If in fact we put Rita through the laparoscopic surgery and it was determined that the Lymphoma was back, Margarita would immediately be put on Prednisone anyway – so that is what we decided to try first. Margarita began Prednisone (5 mg twice daily) on January 21, 2020. We need to be vigilant in watching for any changes or additional symptoms since the Lymphoma has a higher chance of going undetected with the use of Prednisone. A recheck of her bloodwork to see if the Prednisone lowered her liver enzyme values is scheduled for February 4, 2020 with our primary veterinarian, Dr. Campbell.

Margarita’s medical team is quite confident that Rita’s elevated liver values are caused by liver disease, and not Lymphoma. We put our faith and trust in this team and are certain we made the right decision for Margarita.

The unknown is the most difficult part of this. In addition, just because it more likely to be liver disease is not a reason to be completely relieved. Liver disease could also be a life-threatening issue for Margarita. One thing we are certain of is that Margarita is a fighter. We are praying that whatever may be causing Rita’s liver values to be elevated is something that we can help her overcome.

The Start of Prednisone

Januaty 25, 2020

On the 5th day of being on Prednisone, Margarita began to exhibit some of the common side effects:

increased hunger, thirst and urination
panting

However, she also was extremely unsettled – very upset and pacing. We put a call in to our primary veterinarian, Dr. Campbell. She instructed us to reduce the Prednisone to 5mg in the morning and to stop Rita’s nighttime dose to see if it would settle her down. Luckily Margarita did not mind wearing doggie diapers, as her bladder was releasing beyond her control.

January 26, 2020

Margarita’s bladder emptied throughout the night without her realizing. She woke up Sunday not interested in food and acting lethargic. We monitored her extremely closely throughout the day. However, by that evening, Margarita was stabilized on the reduced Prednisone dosage, gained interest back in food, and did not need to wear the doggie diapers any longer.

6 Month Post-Chemo Check-up with New Oncologist / 10 Months in Remission

Margarita and I met her new oncologist, Dr. Jennifer Baez , at the Center for Animal Referral and Emergency Services (CARES) on January 28th. Dr. Baez entered the room, and immediately following introductions, smiled and said, “She’s a survivor! She’s one of the lucky ones – not everyone can celebrate that.” I immediately burst into tears. It was like Dr. Baez somehow knew I needed a little gratitude-refresher! I was overwhelmed with appreciation and happiness that we are approaching what will be one more year of being lucky enough to have Margarita in our lives.

Dr. Baez was extremely compassionate and thorough. After reviewing Margarita’s case, Dr. Baez suggested to continue monthly physical check-ups with her, and for Margarita to have an abdominal ultrasound when she reaches her “1 year in remission” date.

10 Months in Remission Check-Up with Primary Veterinarian

Margarita skipped this visit for the month of January for a couple of reasons. First, she had seen our primary veterinarian, Dr. Campbell, earlier in the month. Secondly, she will see Dr. Campbell in just a few days for the two-week blood work re-check on her liver values, where Dr. Campbell will also do a physical exam on Margarita. With Dr. Campbell’s blessing, we decided that it was best not to stress Margarita with another doctor’s appointment this month.