Rectal adenocarcinoma treatment options

Re: Rectal adenocarcinoma treatment options

Daria McLennan — Wed, 13 May 2015 19:19:22 GMT

Many thanks Gerry for your frankness, that helps a lot in my decision making. Having had some major surgery myself in the past, I'm not sure I'd take this option if I were in the human equivalent of Roma's situation and could comprehend the potential point of it all.

Daria

Re: Rectal adenocarcinoma treatment options

Gerry Polton — Wed, 13 May 2015 16:13:40 GMT

I'm replying twice because I totally agree. This is something that really winds me up. Along with an ability to do something comes a responsibility to judge when not to do something. I am really sorry but I hate nothing more than hearing about 'exciting surgery'. I was that person once and so I say this out of a desire to simply be honest and not to give the impression of superiority, far from it. However, I saw the results of my enthusiasm and chose to narrow my skill set. I was the lucky one who had the opportunity to do so but the reality is that omnicompetence is a thing of the past.

Daria, to answer more fully, I wouldn't present my dog for this surgery. However, that doesn't mean that I think it is wrong for someone else to request it. You will have noted from my original reply that this is a situation where I really really would want a surgeon with real experience of these cases to work on your dog. There aren't that many of them. If someone like you were to come to me for a consultation, I would not advise against surgery, I would tell them that I wouldn't do it to my dog and why. I find that people make the same choices they were going to make anyway when I present my thoughts in this sort of way and bizarrely I think they trust me more if I say I would do something different from them. If a decision was taken to proceed with surgery, at least in principle, then I would rigorously hunt for oncological or other medical reasons for not proceeding, not to prove I was right, but because the potential morbidity is such that we need to be sure that there is as much good quality life ahead of it as there can possibly be in return for any morbidity experienced.

Yours

Gerry the Novice

Re: Rectal adenocarcinoma treatment options

Gerry Polton — Wed, 13 May 2015 16:05:42 GMT

You're very kind, Bob

Re: Rectal adenocarcinoma treatment options

Bob Russell — Wed, 13 May 2015 16:01:28 GMT

[quote user="Gerry Polton"]

You ask a very legitimate question. I wouldn't do this surgery to my own dog. Controversial perhaps.

I don't know of any suitable chemotherapy treatments.

Gerry

[/quote]

I think this is the question we should be asking more and more as specialists push the boundaries further. 1st opinion practitioners should be asking the question on behalf of the owners and owners encouraged to ask when they see a specialist and a difficult decision is to be made.

Perhaps Gerry Polton should be excused the 'novice' poster badge or given the honorary title of 'very important novice'!

Re: Rectal adenocarcinoma treatment options

Daria McLennan — Wed, 13 May 2015 15:57:22 GMT

Oops - sorry, forgot I was in the middle of adding a sentence when was interrupted! The end of the 1st paragraph should read; ' the poor prognosis originally was based on my local oncologist's experience of these tumours, in combination with the invasive nature and histo description and the potential regional lymph node involvement. Unfortunately this oncologist has since moved elsewhere.'

Re: Rectal adenocarcinoma treatment options

Gerry Polton — Wed, 13 May 2015 15:55:35 GMT

You ask a very legitimate question. I wouldn't do this surgery to my own dog. Controversial perhaps.

I don't know of any suitable chemotherapy treatments.

Gerry

Re: Rectal adenocarcinoma treatment options

Daria McLennan — Wed, 13 May 2015 15:50:18 GMT

Thank you all for your input. I forgot to add that the mitotic rate on the latest sample has increased from 6 per 10 hpfs to 20, which although still low is a depressing increase. The poor

I would value anyone's input on whether or not they would put their own dog through a rectal pull through or pelvic split, as I have neither seen nor done one, so the reality of it is an unknown quantity to me. It's not something I would attempt myself and although I've done so before (with my previous dog who had hepatocellular carcinoma), I also find it difficult to hand over complete control to another surgeon who I don't know, and unfortunately I don't know any surgery specialists.

My inclination is to try chemo again as she tolerated it well (and as she's at work with me every day it's not a stressful situation for her and she is a model patient) and I'd appreciate any advice on which agent/s to try.

Many thanks.

Re: Rectal adenocarcinoma treatment options

Gerry Polton — Tue, 12 May 2015 08:35:19 GMT

Hi Daria

I echo Stephen's thoughts. You have done very well so far. This is a relatively low grade malignancy on the basis of the histo findings you report and the duration of the remission you have achieved. Surgery is your best option at this point. Do not attempt it yourself and do refer it to somebody who has experience of a number of similar cases. The morbidity associated with these surgeries can be significant. Please, if you do refer, ensure that you are comfortable that the person taking care of Roma understands the potential complications and has already developed their own satisfactory strategies for avoiding and managing them.

Any suppository therapy is really only going to have a symptomatic relief effect. There was a brief fashion for piroxicam enemas which might have achieved some genuine anti-neoplastic effect in those low-grade cases that were susceptible to the effects of piroxicam via any route. The problem is one of pharmacology: you may recall that the caudal rectal vein returns blood directly into the vena cava rather than the portal circulation, so high tissue doses of drug are attained resulting in a higher risk of adverse effects including renal failure. With suppository steroids, the same is true. Budesonide would be recommended due to its poor transmucosal absorption. That's all very well in principle, but in practice, we are talking abut using it in patients that specifically have broken mucosa, not just a little bit broken either. Please also consider whether this is a long-term palliative strategy we are talking about. I don't know how happy your lovely dog will be to receive frequent (daily?) suppository medication.

If surgery is considered inappropriate, or just simply too much, I would consider a change of NSAID. I wouldn't advocate the addition of a metronomic chemotherapy agent. However, Wynne's colleague who recommended melphalan may know something I don't.

Best of luck

Gerry

Re: Rectal adenocarcinoma treatment options

Hannah Wynne Richards — Tue, 12 May 2015 08:10:47 GMT

I referred a case, and as well as surgery, they've put it on metronomic melphalan.

Good luck,

Wynne

Re: Rectal adenocarcinoma treatment options

Stephen Courtney — Mon, 11 May 2015 21:57:45 GMT

I'm sorry your dog is ill - it must be super stressful and i take my hat off to you having the guts to operate on your own pet ! i won't even vaccinate mine - i get a proper vet to do it...

As i read your history, your last intervention has bought a three year symptom-free period which is excellent. in addition, was that 6 mitoses per TEN high power fields? That doesn't seem very many to me at all, and given the survival time i would think that the tumour is more likely a low grade malignancy - otherwise your dog would not be here now.

I think the last option that remains would be to see if a rectal pull through or similar radical surgery is possible - I'd suggest careful imaging before deciding. And careful choice of surgeon unless you have an appetite for this sort of thing? I'm not familiar with the enemas you describe, given that oral budesonide is active at the mucosal level only if i were to use it I'd probably give it orally...

Good luck whatever your decide x