Canine lymphoma case with a twist

Re: Canine lymphoma case with a twist

Catherine Williams — Mon, 21 May 2012 13:54:35 GMT

Thanks for all the advice, after going round in circles and contemplating various chemo protocols I've decided to just go with the pred, it wont buy us long but I'm hoping it'll give us some good quality of life for a while. Decided that for this boy minimal interference and a short time of life lived to the full is probably the best bet. Got a week off next week so hopefully by then the pred will have kicked in and we'll have some quality time together.

Sadly same day I got his biopsy results come through I also got back the results on a 6yr Goldie that I just removed multiple dermal, subQ + muscle masses from, all of which turned out to be lymphoma. At least I've got all the facts and figures at my fingertips at the moment.....they haven't yet asked me what I'd do...but not an easy one to counsel, makes me wonder how much my advice is influenced by these things

Thanks for all the best wishes

Re: Canine lymphoma case with a twist

Rajat — Mon, 21 May 2012 12:54:46 GMT

Dear Catherine

Condolences on your own dog getting lymphoma -I think dealing with our own pets is one of the toughest times re decision making . I think you have got some excellent advice above just want to add a few things

Re doxorubicin - As others have said there is evidence of prolongation of remission and survival times in dogs treated with Doxo containing protcols vs not.

there is a protocol for treating lymphoma- a modified madison wisconsin protocol which runs 19 weeks cf 25, and steroids only for the first week or 2. There is no maintenance phase. It has shown equivalent results to the 25 weeker. I have used this for the last 3 years with good results, including my colleagues I would say 6cases in total.it is is less intense, gives weeks off in between and is 'nicer' for dogs and owners than the 25 weeker.

Evaluation of a 6-month chemotherapy protocol with no maintenance therapy for dogs with lymphoma

J Vet Intern Med. 2002 Nov-Dec;16(6):704-9.

Laura D Garrett¹; Douglas H Thamm; Ruthanne Chun; Robert Dudley; David M Vail

Remember, although rare clinical cure is possible - we have seen 2 cases cured in the last 3 years out of maybe 10.

The quoted cure is <5 % though so while I mention it to owners I ask them not to consider it at all likely.

I think youhave to consider will your dog tolerate chemo? will he be happy for IV injections?

Re doxo- there are options. Hospira (hospira.co.uk) will send you doxorubicin pre made up in syringes next day if needed. Add it to saline or put it thru a syringe driver with concurrent saline and hey presto youre done, no fume cupboard required (only if mixing a powder) The thing I worry about most is extravasation so will not hesitate to put another cath in a different leg if it doesnt insert absolutely perfectly the first time. theres many good guides about giving chemo in the literature. Alternatively you could visit a practice/specialist that does it regularly for the first dose or 2 to watch then do subsequent ones yourself.

you can also use epirubicin - lower risk of cardiomyopathy. with dox, cardiomnyopathy will likely not happen till you exceed 180mg/m2 whihc is 6 doses which wont happen in the first round of chemo (ie the 19weeks). If you choose to do a second round with dox,you can then use Cardioxane (dexrazoxane) to reduce this risk of cardiomyopathy. Bloody expensive tho, used it once, £500 per shot.

Epirubicin as part of a multi-agent chemotherapy protocol for canine lymphoma.

Vet Comp Oncol. January 2011;0(0):.

Liposome encapsulated dox is another option tho not v tried and tested, but is a subQ inj

http://jpet.aspetjournals.org/content/289/2/1128.full

Note single agent dox meant to do poorly in cats but better in dogs.

Intermittent Single-Agent Doxorubicin for Treatment of Canine B Cell Lymphoma

ACVIM 2011

I can send you the 19 week protocol if you like or any other info. I always pre treat with cerenia for vinc/dox and frusemide for cyclophos. Salazopyrin for colitis if develops post dox (usually 3-5 days post injection)

Lastly, I'd encourage you to decide sooner cf later- the disease is progressing internally, and you may have better results (remission times) the sooner you start/decide on whether you will or wont do chemo.

all the best for you and your dog

cheers

Raj

Re: Canine lymphoma case with a twist

Christopher Saul — Fri, 18 May 2012 13:35:25 GMT

Firstly, my sinerest condolences this is an awful time for you, I really am so sorry.

I'd echo Andy's thoughts really, that what is the best option is the one that you are most familiar and comfortable with... if you feel uncomfortable about doxorubicin, dont go there. The general consensus is that a CHOP -type ( doxo, vinc, cyclo, pred) protocol is generally the one associated with the longest survival times, though in the grand scheme of things the evidence base for this is relatively small

With lymphoma patients there will always be a sub population which will survive much longer than average, and also a few which suvive for less time, probhably as a result of there being many individual lymphoma phenotypes that we cannot yet distinguish with our current level of understanding. My own belief is that the survival for any individual is as much to do with the lymphoma itself rather than exactly which protocol you use.... In my own experience I have had so far 2 very long term (one 2 and a half, one 3 year) survivors who stand out in my memory; one was on a high dose COP and one on a CHOP.

There's no right or wrong answer so you have to do what you're most comfortable with. My current protocol is a 25 week CHOP.

good luck

Chris

NB .... With regards practicalities of doxorubicin, you can buy it in a ready-mixed form so you only have to draw it up. I wear a disposable gown, goggles, mask and a pair of rectal exam gloves under the double latex gloves. I draw my drugs up inside a large clear plastic bag, so that if I do have a spillage it is contained withint the bag, and I can draw the rectal gloves inside out over the large plastic bag thus containing the spillage.

Re: Canine lymphoma case with a twist

Simon Neuhoff — Fri, 18 May 2012 11:17:40 GMT

[quote user="Martin Atkinson"]

[quote user="robloxley"]

[quote user="Mark Hedberg"]I think it was better than trying to stretch out every last minute[/quote]

Agreed, but with a good lymphoma protocol we'd hope to get a good long period in complete remission (i.e. no outward signs of the disease) with low side effects which I think is a good aim. If we can't achieve all of that then yes I would question pursuing further treatment as just stretching out the inevitable.

[/quote] Isn't it strange that we would encourage our clients to have chemotherapy for their pets but wouldn't necessarily give to our own? Heck I'd think twice about having it myself - but then I think about my hero whom I quote in my signature. I guess it depends on the nature of the beast, Are we all hypocrites?

[/quote]

I don't encourage chemotherapy to my clients. Offer it certainly, in house options or referral. But I definitely don't push for it and I personally would not put my cats through it. I think this is an area where your decision making is coloured very much by your personal experiences with chemo, in your patients and also in family members etc. Whilst I try to give an objective and balanced viewpoint as best as possible I suspect subconsciously I do discourage my clients because I seem to do fewer chemotherapy treatments than my colleagues do.

Re: Canine lymphoma case with a twist

Kate Dawes — Fri, 18 May 2012 10:41:24 GMT

My cat had lymphoma a few years ago and I found it very difficult to make decisions - all rational thought seemed to go completely out of the window.

We tried leukeran and preds for a short time without any success, I didn't go for COP as whilst he was v affectionate at home he was very nervous at the surgery and hated being messed about with. He was PTS a very short time after diagnosis. Whilst I occasionally wonder what if..... I don't regret the decision - he had a good life and I didn't want lots of interference. I think it depends very much on the character of the patient. I've seen plenty of dogs and cats that don't seem to get stressed by the iv's and blood tests and do very well. There's always the option to try a few treatments and see what happens? Don't have any experience of doxirubicin I'm afraid. If there isn't a known advantage to it I think I would go with COP if that's what you're familiar with.

Re: Canine lymphoma case with a twist

Mark Hedberg — Fri, 18 May 2012 10:31:20 GMT

[quote user="Martin Atkinson"]

[quote user="robloxley"]

[quote user="Mark Hedberg"]I think it was better than trying to stretch out every last minute[/quote]

Nope, we're all scientists who are still grappling with the question of what to do when logic meets emotion. It's no crime to admit you don't know what you'd do when it's you...we all react differently when it's us, because it obviously has a far greater effect on us - it's not a fee this time, it's my life!

I don't think it's hypocritical. I think it's honest to admit you don't know what you'd do if it was you. I'd like to think if my cat could have been cured I would have; on the other hand, he couldn't and so he wasn't.

I had him from when I was 4 until I was away at uni. (I was gutted I couldn't get home.) There's a lot of memories, a lot of emotion involved. :)

Re: Canine lymphoma case with a twist

Martin Atkinson — Fri, 18 May 2012 10:11:35 GMT

[quote user="Lorna McHardy"]

Just wondering... what do you all do with the "what would you do" question?

[/quote] I normally hedge around it by saying I don't know until the time arrives because one's thought processes then become less rational. Sadly I confess that there are occasions when the decision is a balance that I may say I'd do it to encourage people to get a job done so I get the fee. Not very altruistic maybe but a fact of life, but I wouldn't do something I honestly knew was unnecessary or impractical.

Re: Canine lymphoma case with a twist

Lorna McHardy — Fri, 18 May 2012 09:53:32 GMT

[quote user="Martin Atkinson"]

Isn't it strange that we would encourage our clients to have chemotherapy for their pets but wouldn't necessarily give to our own?

[/quote]

I wouldn't. Offer, certainly. But if I wouldn't give it to my own, I wouldn't encourage... but ultimately, it's the owner's decision.

Just wondering... what do you all do with the "what would you do" question?

Re: Canine lymphoma case with a twist

Martin Atkinson — Fri, 18 May 2012 09:29:08 GMT

[quote user="robloxley"]

[quote user="Mark Hedberg"]I think it was better than trying to stretch out every last minute[/quote]

Re: Canine lymphoma case with a twist

Mark Hedberg — Thu, 17 May 2012 20:20:44 GMT

[quote user="robloxley"]

[quote user="Mark Hedberg"]I think it was better than trying to stretch out every last minute[/quote]

[/quote]True; also was a different situation for me - my cat didn't have cancer - just got old, developed megacolon, arthritis, dementia, and he just wasn't able to do anything he used to like to do. If we could have treated him, ho yes we would have. :)

Re: Canine lymphoma case with a twist

Bob Russell — Thu, 17 May 2012 16:38:54 GMT

My GSD's father has lymphoma so we have thought a bit about what we would do if he has the same problem. At the moment (while it is still academic!) we would go in with the big guns blazing but stop if the side effects were too great.

Best of luck!

Re: Canine lymphoma case with a twist

Rob Loxley — Thu, 17 May 2012 16:22:18 GMT

[quote user="Mark Hedberg"]I think it was better than trying to stretch out every last minute[/quote]

Re: Canine lymphoma case with a twist

Catherine Williams — Thu, 17 May 2012 10:37:25 GMT

That's one of the decisions I'm battling with, I know chemo can extend the time, but I want what time I've got left to be as good as possible. I'm debating just 6-8wks of fun with just a big appetite and a thirst versus the potential of a longer time but a lot of meds & interference. Given he is atopic, arthritic and has low level inflammatory bowel disease I'm concerned side effects may be a problem. He's generally pretty well in himself, he is a very good patient, he's used to the surgery and is often used as practice dog, blood sample donator etc but I don't want his life to be all about the chemo. We've had a couple of good successes with COP but equally I've had some cases where it hasn't really bought us that much longer, maybe 4-5mth rather than 2 but there's been a lot more interference in the dog's life.

lot of sleepless nights debating

Re: Canine lymphoma case with a twist

Mark Hedberg — Thu, 17 May 2012 09:10:15 GMT

[quote user="Martin Atkinson"]

On the other hand as I've never got particularly attached to my pets I may not do anything rather than see it suffer pain for little gain and PTS when the time came - sorry.

[/quote]

To be honest, I think that many people who are highly attached to their pets would come to the same decision. I had a cat for 19 years; and I was sorry as anything when it came time to say goodbye, but I think it was better than trying to stretch out every last minute. He had excellent innings, and he's in a better place now.

Re: Canine lymphoma case with a twist

Martin Atkinson — Thu, 17 May 2012 09:00:15 GMT

I've only ever used doxorubicin as part of a M-W protocol so can't comment on it as a stand-alone product. I know Gerry Poulton has been keen on using it in cats as a single agent with encouraging results but IME it has been the weak link in terms of side effects and more owners have elected to stop it than continue because of the GI side effects. If it was my dog I would also use the M-W protocol but may well substitute the dox for l-asp if the side effects were unacceptable. If not I'd rather use COP than dox as a single agent because although it is more time consuming the side effects are much less for no apparent difference in effectiveness. On the other hand as I've never got particularly attached to my pets I may not do anything rather than see it suffer pain for little gain and PTS when the time came - sorry.

Re: Canine lymphoma case with a twist

Rob Loxley — Thu, 17 May 2012 00:08:27 GMT

My current understanding is the MW has the best overall 1st line results, however with associated cost and potentially more side effects. As per Martin the jury seems undecided on l-asp or not.

I went to a CPD where the speaker suggested single agent dox was as good as a standard course of COP. Also fewer visits to the vet and blood tests are required, but there are the higher potential hazards.

We all have seen cases that have done well on just pred but also I'm sure many that haven't (and equally cases that do poorly on MW).

Re: Canine lymphoma case with a twist

Andrew Kent — Wed, 16 May 2012 21:07:17 GMT

The interesting thing about doxorubicin is that it is difficult to assess how effective it is in lymphoma cases as we tend to introduce it 3-4 weeks into a chemo protocol when most dogs are in remission anyway. It has always been seen as being integral to treatment but I am not sure this is backed up my much. It may be that you would be better off with a COP protocol if you are unfamiliar with doxo. If it were my own dog I would use a modified Madison-Wisconsin as Martin suggested and I would think if you are going to go for chemo you should go for the option that is most likely to work! Andy

Re: Canine lymphoma case with a twist

Busybee — Wed, 16 May 2012 20:27:42 GMT

[quote user="Bob Russell"]We have a very aggressive GSD on preds alone and the improvement has been dramatic (1 month on now) but this is clearly not likely to give an extended period of remission.[/quote]

I have one lurcher on pred only, now 2 months post-diagnosis and doing very well - COP protocol refused as dog very nervous and gets extremely stressed being in vets. Just about to start an old collie on pred alone also - COP refused on cost grounds.

Re: Canine lymphoma case with a twist

Mark Rowland — Wed, 16 May 2012 17:12:07 GMT

Nothing more to add but my sympathy Hope he gets on ok From another Spinone owner :-)

Re: Canine lymphoma case with a twist

Martin Atkinson — Wed, 16 May 2012 17:09:59 GMT

Why not preds and dox then, surely you won't need the NSAIDs then for the OA anyway?

Re: Canine lymphoma case with a twist

Hannah Wynne Richards — Wed, 16 May 2012 16:49:39 GMT

It's awful when it's your own animal that's ill My sympathy

Wynne

Re: Canine lymphoma case with a twist

Catherine Williams — Wed, 16 May 2012 16:11:10 GMT

I was looking at doxorubicin because I could keep him on the nsaids and because it was intervention once every 3wks rather than the weekly COP so hoping less time being a patient and less time feeling poorly immediately post chemo might maintain better quality of life. I'd rather have a little less time with 1-2 days a month of pulling around than a little longer but wkly chemo sessions. There seems to be a bit of overlap on survival times, he might only get 5-7mth on doxo but low end COP survival times seem to be similar.

Re: Canine lymphoma case with a twist

Bob Russell — Wed, 16 May 2012 15:12:16 GMT

I mix the stuff up outside. I work on the assumption that a gentle breeze is almost as good as a fume cupboard! Lots of good protective clothing!

Limited number of times you can give it because of cardiac damage. Dramatic results but not particularly long survival time. Not my first line. I would agree that high dose preds should make the atopy magically go away and perhaps tramodol if necessary (mixed opinions on efficacy!) in place of NSAI.

We have a very aggressive GSD on preds alone and the improvement has been dramatic (1 month on now) but this is clearly not likely to give an extended period of remission.

Re: Canine lymphoma case with a twist

Martin Atkinson — Wed, 16 May 2012 14:58:56 GMT

First thing I would think is that with all the steroids he is going to get with chemo he wont need any NSAIDs for his OA and his atopy will be nuked. There is a separate thread on administration of chemo on the this forum and although clearly you have to take great care I personally would have no worries with giving Doxorubicin without a fume cupboard or a closed administration system, I just take great care and make sure I'm the only person at risk. I've had good success with a modified Madison-Wisconsin protocol (one dog still in remission over 3 years later), I don't have it in electronic form but if you give me a fax number I can fax it to you. It includes l-asparaginase which my be a bit expensive if you aren't insured but not everyone believes it is of value anyway. The only problem I have with Dox is the GI side effects (oh and one Cavalier that died from heart failure so check his heart first!) and if it was my dog I may not want to continue if they were severe.