11 Months in Remission

Margarita had a fantastic month!

Rita received another box of amazing goodies from Chewy.com from a friend of ours!

Margarita’s Aunt Jen brought her a treat from McDonalds when she came to visit

Broom Challenge accepted! Rita joined in on the magic of February 10th… and voilà!

Armageddon Brewery opened its doors, and Margarita was their first 4-legged visitor!

We had the most special Valentine’s Day ever when the Medford Lakes Police Department came to the house to help Sweet Reet check off another Adventure List item (take a ride in a police car)!

February 21st was one year since Rita’s splenectomy. While it may seem silly to celebrate having an organ removed, had her spleen remained, Rita wouldn’t be here with us today.

How about your own National Day to help celebrate 11 months in remission?! National Margarita Day was celebrated February 22nd.

At Rita’s last oncology visit, Dr. Baez (Margarita’s new oncologist) cleared her to do whatever activities she pleases. We have been incorporating longer walks into our schedule, and this month Margarita took her first hike since her diagnosis last year.

Margarita, Porter, and their cousin Clyde enjoyed a nice hike together!

Margarita has accompanied me at school many times this month. At least once a week I come home for lunch, and after all the pups go potty, Rita will head back to school with me for an hour visit with the students. The students are thoroughly enjoying her company, and Margarita is soaking up all the love, pets, and belly scratches!

February 27th was one year since we found out Margarita had Lymphoma. We are truly blessed to be able to “celebrate” this one-year mark, as we know many dogs are not as lucky as our Sweet Reet to have made it this far. She is truly a Lymphoma Warrior!

Monthly Primary Veterinarian Check-Up

On February 4th, 2020 Margarita saw Dr. Campbell and had her blood work drawn again to retest her liver enzyme levels.

The results were as follows:

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)
  4. 500 (2/4/20)

AST Normal Range: 16-55

• Rita’s AST Values:
  1. 146 (12/9)
  2. 146 (12/26)
  3. 56 (2/4/20)

As you can imagine, we were thrilled! Dr. Campbell instructed us to increase Margarita’s Denamarin and have her blood work retested in 4 weeks. Rita will visit with Dr. Campbell again March 3rd to have this test done.

Current Liver medication and supplement dosage:

• Prednisone:
  • 5 mg in AM
• Denamarin:
  • 1 tablet twice daily (increased from the prior 1 tablet daily)

Dr. Campbell also suggested that we contact Margarita’s cardiologist, Dr. Bossbaly, in hopes to have her chemo-induced-DCM recheck appointment moved up, and also to inquire about the possibility of taking her off of the cardiac medication, Pimobendan. The less medication Rita is on, the better…this way her liver is not overworked with processing medications.

I was not able to get a sooner appointment with Rita’s cardiologist, Dr. Bossbaly, but I was able to speak with her. Dr. Bossbaly wants Margarita to stay on the Pimobendan at least until the appointment in June because she is doing so well on it. Dr. Bossbaly does not feel this medication will have any effect on Rita’s liver values. She also said that she was concerned that if Rita’s heart disease got worse, it would have even more of effect on her liver.

Monthly Oncology Check-UP

I was surprised to find out upon her exam that she gained over 2 pounds. Last oncology visit she was 52 pounds, and this visit she weighed in at 54.8 pounds. This could be a side effect of the Prednisone, and I plan to discuss this at our next monthly veterinary appointment with Dr. Campbell. On exam, Margarita’s heart rate and rhythm were normal and Dr. Baez could detect a low-grade heart murmur. Rita’s peripheral lymph nodes were normal and she was in good body condition.

Dr. Baez said Margarita looked fantastic! I shared with Dr. Baez that I was interested in exploring nutritional options for Rita and possibly adding in some holistic care to maximize all the treatment options for her. Doctor Baez provided me with some referrals for both a holistic vet as well as a nutritionist. I plan to discuss this information with our primary veterinarian, Dr. Campbell, at our next monthly appointment.

Although I rehearsed in my head many times, the next part of my conversation with Dr. Baez was very difficult for me to say out-loud. After careful consideration of Margarita’s current level of liver disease, intestinal disease, and heart disease, Brian and I feel as though if her Lymphoma resurfaces, another round of chemotherapy would not be a fair option for our Sweet Reet. However, if those diseases improve, and she is deemed healthy enough, we would absolutely explore chemotherapy again as an option. In the meantime, we are inquiring about any and all ways we can support Rita in hopes to keep her in remission for as long as possible.

If Margarita’s liver values decrease with her next blood test, we are going to hold off on her abdominal ultrasound until June (which would be 6 months since her last ultrasound). If her liver values increase with the next test, we will order the abdominal ultrasound to be completed ASAP.

With the “1 Year in Remission Anniversary” approaching, Margarita’s oncology visits will also now change from every month to every two months until she reaches her “18-months in Remission Anniversary.” At that point we will then increase the time between oncology visits to quarterly, (every 3 to 4 months). Dr. Baez asked us to continue to monitor Rita as we have been doing, and to reach out if we have any concerns. Margarita will have her next oncology visit with Dr. Baez in April.

This Month’s Treat

This month Margarita enjoyed a small taste of Bacon, Egg and Cheese Tacos with a side of Mac-n-Cheese from TGI Fridays !

We are looking forward to March – we have some pretty amazing milestones to celebrate!

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….

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.

This Month’s Treat

Margarita enjoyed a few bites of Roadside Sliders and Sweet Potato Fries from The Cheesecake Factory !

Month 7 of Remission

Margarita had an exciting and busy month. She traveled all the way to Iowa on an 11-day trip to cheer on her brothers and sisters at the DockDogs World Championship.

Rita also checked-off another one of her adventure list items! We took Margarita to The Library II for a specially-selected cut of filet mignon! Click HERE to see her special-cut steak!

We also did our part to participate in National Canine Lymphoma Awareness Day, by publishing a post to help others understand this disease and to learn how to check your dog for signs of cancer.

4 Month Check-Up with the Cardiologist

Back in July 2019, Margarita was diagnosed with Dilated Cardiomiopathy, thought to be caused by Doxorubicon (Adriamycin) toxicity. Rita’s heart was enlarged, and she had a grade 3 heart murmur with ventricular premature contractions. On November 5, 2019 Margarita saw her cardiologist, Dr. Bossbaly for her 4-month re-check.

Rita waited patiently for Dr. Bossbaly:

Dr. Bossbaly did a a recheck EKG and echocardiogram. Rita’s heart murmur was graded as a 2 out of 6. The murmur was described as a wispy band shaped holosystolic murmur at the left apex, and audible only faintly on the right. Her heart rate was 118 bpm and regular, and her lungs were also clear. Additionally, there was also no arrhythmia recorded at this time on a long-recorded EKG as well as during the entire echocardiogram.

This means that Margarita’s heart disease is it stable on the current medication. Even though Margarita’s heart showed improvement, Dr. Bossbaly wants her to continue with her current medication and supplements until we have the next scheduled cardiology appointment in 6-8 months. Margarita’s current medication and supplement schedule will remain as follows:

• Pimobendan: 5mg eery 12 hours
• L-Carnitine: 1 gram twice daily with food
• Taurine 500mg twice daily with food
• Coenzyme Q10: 30 mg once daily
• CAS Options: 1 tablet twice daily

With the indication of Margarita’s marked improvement last month, I must admit that I neglected to continue monitoring her sleeping respiratory rate (SRR), thinking it wouldn’t be necessary considering she was making such great improvements. I was incorrect. Dr. Bossbally instructed me to resume tracking Rita’s SSR. Dr. Bossbaly explained that even when improvement is noted, taking Margarita’s SSR is extremely important for anticipating fluid shifts and the onset of congestive heart failure. For those of you wondering why it is important to monitor your pup’s sleeping respiratory rate and how to count/track it, here is the information I was given:

• Why monitoring your Pup’s respiratory rate is extremely important:
  • The sleeping respiratory rate is a subtle and sensitive indicator of changes in your fur-kid’s condition.
  • Increases in the sleeping respiratory rate may indicate the development of heart failure in your pup.
  • Your doctor will want to know if your pup’s sleeping respiratory rate goes above 30, or if there seems to be an upward trend (a steady increase in rates heading towards 30) . The point is to catch the change in the sleeping respiratory rate before it reaches 40 or 50 and could become an emergency situation.
  • Is important to note that he small increase in this sleeping respiratory rate may not be accompanied by any other changes such as an increased effort to breeze, excessive panting, coughing, or restlessness. These are important to note but it is likely that once you see the signs, the sleeping respiratory rate will already be elevated.
• Why count the sleeping respiratory rate?
  • If your pup has been diagnosed with heart disease, it is unfortunately a progressive disease in most cases. Monitoring it on a regular basis will help avoid a health crisis; It will help avoid an emergency visit to your veterinarian, hospitalization for multiple days, and the sudden increase in financial responsibility occurring with emergency hospitalization.
  • Tracking sleeping respiratory rates every now and then is not ideal, as this number can change overnight. Additionally, just “watching” or “eyeballing” is not accurate enough.
    • **EXAMPLE: Say your pup’s sleeping respiratory rate is 24 (in 15 seconds you count 6 breaths). Now let’s say that your dogs sleeping respiratory rate increases to 32 (in 15 seconds you counted 8 breaths). The difference between the two instances is only a breaths per minute – a hard thing to notice if you’re not actually tracking the breaths. Additionally, 32 is an elevated and abnormal sleeping respiratory rate.
• How to count the respiratory rate:
  • Count the respiratory rate by watching your dogs chest go up and down (each “up” and “down” equals one breath cycle). Use a clock or a watch with a second hand, count the number of full breaths in 15 seconds, and multiply that by 4 to get the respiratory rate for one minute. Log these results on a computer, in a journal, on your calendar, or on a note in your phone.
  • ***NOTE: We have found it easier to download a sleeping respiratory rate app. The app will help you keep count of the breaths, and also save the results and display them in a graph that you can email or share with your pup’s doctors. The two most helpful apps we have found are:
    • Cardalis: This app is free and will help you to measure your dog’s respiratory rate, record it as a graph. This results graph can be e-mailed to your dog’s doctors. Cardalis is best if you have only one fur-kid with heart disease, as it only allows for tracking of one dog/cat.
    • Maolife: This app is also free, and allows you to track the respiratory rates of multiple dogs/cats. Results are recorded in a graph. The Maolife app also allows multiple people to manage the same fur-kid. Additionally, this app has the capability to share your recorded results with others.

Lastly, I discussed the possible removal and biopsy of Rita’s mammary mass with Dr. Bossbaly. Doctor Bossbaly explained that Rita is still at a higher risk. If it becomes necessary for the mass to be removed and biopsied, Dr. Bossbaly’s suggestion is to have it done at VSEC were a board-certified anesthesiologist can monitor the protocol that Dr. Bossbaly recommends. If we would rather have the mass removed by our primary veterinarian, Dr. Campbell, the procedure can be sent over to Dr. Campbell for her to decide if she is comfortable doing the surgery along with the recommended protocol.

Monthly Check Up with Oncologist

On November 15 Margarita had a visit with her oncologist, Dr. Risbon. Rita’s physical examination was normal, and there was no evidence to suggest recurrence of lymphoma. Dr. Risbon could not hear a heart murmur today, and reported that Rita’s heart rhythm is normal. Dr. Risbon also evaluated Rita’s mammary mass and said she thought the thickened tissue portion appears to feel smaller. However, the small mass (approximately 3-5 mm) seems unchanged from previously. Dr. Risbon shared that she is pleased with Margarita’s progress, and feels as though she is doing well in maintaining her remission.

First Day Back “on the Job” since Lymphoma Diagnosis

Margarita made a very short surprise-visit with me at my school and made some students extremely happy!

We kept the visit with the kids to only 30 minutes. The visit was perfect and did not exhaust Rita.

Monthly Check Up with Primary Veterinarian

On November 22 Margarita visited with our primary veterinarian, Dr. Campbell for her monthly post-oncology appointment. Dr. Campbell said she was very pleased with the improvement in Margarita’s heart murmur, as well as her Lymphoma remission. While the original mammary mass was being checked, Dr. Campbell found a second tumor on a different gland.

Mammary tumors are extremely common in female dogs – especially those who were spayed later in life. Spaying a female after the first or second heat cycle significantly reduces the risk of the dogs developing a mammary tumor. Since Margarita was not spayed until we took her in as a foster at age 6-ish, we knew mammary issues were a possible issue. If you are reading this and are immediately thinking, “Why is the vet not aspirating the mass to look at the cells?”… then you are not alone. I immediately asked Dr. Campbell if we could aspirate the original mass when it was discovered. Dr. Campbell explained that unfortunately a fine needle aspiration of the mass usually has a very low diagnostic value when it comes to discerning between malignant or benign tumors. Unfortunately, the only way to diagnose a mammary tumor as benign or malignant is to surgically remove them and send the mass out for a biopsy.

The good news is that Dr. Campbell explained that approximately 50% of mammary tumors are benign. My immediate response was, “What if the masses are malignant?” Dr. Campbell informed me that even if the masses are removed and found to be malignant, there is no proven effectiveness of chemotherapy for the treatment of malignant mammary tumors in dogs. If deemed necessary, the tumors would be removed and the biopsy would tell us a more detailed story of what treatment (if any) would be needed.

I have many other questions about these tumors – such as the prognosis if they are found to be malignant. I know the best prognosis is directly associated with early detection. I decided it was best to not ask any other questions until I “have” to, and to do my best to remain positive that Margarita will be lucky enough to be included in the “50% benign” grouping. In the meantime, I am focusing on the many good days we have celebrated with Margarita, and extremely thankful that I have Dr. Campbell as such a patient and informative teacher during this process.

Margarita will continue to see Dr. Campbell on a monthly basis so that both Margarita’s oncologist and Dr. Campbell can keep a close watch on the mammary masses in order to determine the best plan for Margarita moving forward.

This Month’s Treat

Margarita enjoyed a few bites of a grilled cheese from Panera Bread!