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So Atticus went to the vet this morning for his second chemotherapy drug, cyclophosphamide. Before they gave him the pill, they ran the regular tests and checked his weight…he gained a pound and his blood test results were “Phenomenal”!!!
So, cyclophosphamide- the vet gave it by mouth. They gave us a Diuretic to encourage him to pee and prevent the side effects discussed below (excerpt from Lymphoma: Which Chemotherapy Protocol and Why? by Ruthanne Chun, DVM, Dipl. ACVIM (Oncology):
Cyclophosphamide, an alkylating agent, may be administered
orally or intravenously. When given orally, absorption
is excellent and bioavailability is as good as with intravenous
administration. The potential for myelosuppression and gastrointestinal
upset after cyclophosphamide is moderate. The
specific side effect of major concern with cyclophosphamide
is sterile hemorrhagic cystitis (SHC), which occurs secondary
to elimination of irritating metabolites through the urine.
SHC may occur after oral or intravenous administration.
This side effect is not cumulative; it may happen after the first
dose of cyclophosphamide. Because there is no effective treatment
for SHC, prevention is key. Administration of a single
dose of furosemide at the time of cyclophosphamide is reported
to greatly diminish the development of SHC. Also,
simple management issues such as allowing the patient out to
urinate frequently for 3 days after drug administration and
encouraging intake of plenty of fluids may prevent SHC.
The following excerpt is from http://en.wikipedia.org/wiki/Cyclophosphamide:
Cyclophosphamide is converted by mixed function oxidaseenzymes in the liver to active metabolites[12]. The main active metabolite is 4-hydroxycyclophosphamide, which exists in equilibrium with its tautomer, aldophosphamide. Most of the aldophosphamide is oxidised by the enzyme aldehyde dehydrogenase (ALDH) to make carboxyphosphamide. A small proportion of aldophosphamide is converted into phosphoramide mustard and acrolein. Acrolein is toxic to the bladderepithelium and can lead to hemorrhagic cystitis. This can be prevented through the use of aggressive hydration and/or mesna.The main effect of cyclophosphamide is due to its metabolite phosphoramide mustard. This metabolite is only formed in cells that have low levels of ALDH.
Phosphoramide mustard forms DNA crosslinks between (interstrand crosslinkages) and within (intrastrand crosslinkages) DNA strands at guanine N-7 positions. This is irreversible and leads to cell death.
Cyclophosphamide has relatively little typical chemotherapy toxicity as ALDHs are present in relatively large concentrations in bone marrow stem cells, liver and intestinalepithelium. ALDHs protect these actively proliferating tissues against toxic effects phosphoramide mustard and acrolein by converting aldophosphamide to carboxyphosphamide that does not give rise to the toxic metabolites (phosphoramide mustard and acrolein).
The articles sound scary but Krisann says he he is peeing a lot and drinking a lot also which makes me feel good.
He continues to do really well, his appetite is endless, no unusual eliminations, no fever, rash, furloss…He is doing great on chemotherapy!
Tonight was time to make Atticus’s food which involves boiling chicken legs and thighs and livers down to a mushy mess. I was disgusted completely, to the point of almost puking. But Krisann did most of the work, Peter barely did anything, even when he was pulling chicken he used the fork…it was pathetic on his part. Hardly what I expected. Krisaan is the King of pulling chicken which is ridiculous because she is the vegetarian in the house. GO KRISANN!
He has been doing well the last couple nights, since administration of the first two chemotherapy drugs. Last night I suspect his stomach was upset because when I got home from work and let him outside, he kept eating grass. Shortly after this, I took him back inside and made his dinner- dry dog food mixed with boiled chicken and rice. Along with dinner, he gets a half Pepcid and a Prednisone.
I didn’t notice any side effects after that. His energy was ok, no fever, vomiting or diarrhea. He does have room-clearing gas, which is a likely side effect from the chicken & rice we’ve been adding to his regular meals.
I wanted to thank Jen-Jen for the wonderful articles she emailed me. They were packed with information about doggie lymphoma, diagnosis, treatment and outcomes…One article discussed the usage of doxorubicin and multiple other drugs (the chemo approach we have chosen for Atticus).
As expected, it has also been found that those dogs experiencing
greater side effects tend to have a better overall
response to treatment.
Body area has traditionally been used to calculate
drug doses, resulting in smaller dogs being given a higher
dose than larger dogs and, as such, tending to have better
survival rates.
I haven’t stopped thinking about this since I read it. No, Atticus is not having side effects, but the side effects MAY indicate something stronger going on inside him- possibly working harder to combat the tumors. On the other hand, he is small and may be getting a higher dose unless they are basing it on his body area…
This is something we need to discuss with the vet, whether we could increase his doses of medicines just a bit, but monitor him closely to ensure side effects are not inhibitive. Some side effects are tolerable if it helps him in the long run.
But we are just looking for remission, not a cure; and I don’t want him to suffer. Need to read some more…
Information found at http://www.cancer.org/Treatment/TreatmentsandSideEffects/GuidetoCancerDrugs/Vincristine
How does this drug work?
Vincristine is a type of chemotherapy drug known as a vinca alkaloid. It is thought to work by interfering with cancer cell growth when they are dividing into 2 new cells. This eventually leads to cell death. Because cancer cells divide faster than normal cells, they are more likely than normal cells to be affected by this drug.
The following is from http://en.wikipedia.org/wiki/Vincristine
Mechanism
Tubulin is a structural protein that polymerizes to actin microtubules. The cell cytoskeleton and mitotic spindle, among other things, are made of microtubules. Vincristine binds to tubulin dimers, inhibiting assembly of microtubule structures. Disruption of the microtubules arrests mitosis in metaphase. Therefore, the vinca alkaloids affect all rapidly dividing cell types including cancer cells, but also those of intestinal epithelium and bone marrow.
Side-effects
The main side-effects of vincristine are peripheral neuropathy, hyponatremia, constipation, and hair loss.
Peripheral neuropathy can be severe, and hence a reason to avoid, reduce, or stop the use of vincristine. One of the first symptoms of peripheral neuropathy is foot drop: A person with a family history of foot drop and/or Charcot-Marie-Tooth disease (CMT) may benefit from genetic testing for CMT before taking vincristine.[1]
From http://en.wikipedia.org/wiki/Asparaginase:
A different asparaginase is marketed as a drug under the brand name Elspar for the treatment of acute lymphoblastic leukemia (ALL)[2] and is also used in some mast cell tumor protocols. [3] Unlike other chemotherapy agents, it can be given as an intramuscular, subcutaneous, or intravenous injection without fear of tissue irritation.
Mechanism of action as a drug
The rationale behind asparaginase is that it takes advantage of the fact that ALL leukemic cells are unable to synthesize the non-essential amino acid asparagine, whereas normal cells are able to make their own asparagine; thus leukemic cells require high amount of asparagine. These leukemic cells depend on circulating asparagine. Asparaginase, however, catalyzes the conversion of L-asparagine to aspartic acid and ammonia. This deprives the leukemic cell of circulating asparagine.
Side effects in drug use
The main side effect is an allergic or hypersensitivity reaction; anaphylaxis is a possibility.[2] Asparaginase has also been associated with pancreatitis. Additionally, it can also be associated with a coagulopathy as it decreases protein synthesis, including synthesis of coagulation factors (eg progressive isolated decrease of fibrinogen) and anticoagulant factor (generally antithrombin III; sometimes protein C & S as well), leading to bleeding or thrombotic events such as stroke.
I love reading this kind of stuff and figuring it out. Understanding exactly what all these drugs are doing, how the cancer works, etc. makes me feel like I have a better chance fighting it. Plus, isn’t it fascinating to think of how someone comes up with a drug that does this? Who would even think of it?? Amazing minds…Thank you!!!
Atticus did well all night. He had plenty of energy, was very snuggly, without fever or chills, ravenous appetite… BUT…I am trying to remember that not every drug he is given will go down as easily as the injection of vincristine did yesterday.
I am glad to have something to be optimistic about because a few days ago I was struggling to find a single happy thought in what seemed to me to be a bottomless pit of despair. Krisann dropped him off this morning at the vet to receive “Elspar” (l-asparaginase) which he was supposed to get yesterday but they were out of. She will pick him up after her shift at the coffee shop. I will miss his renewed excitement when I come home from work but I think it’s a good time because the elspar can cause allergic reactions. Since he will be at the vet all day, they will keep an eye on him until Krisann can pick him up tonight.
Giggles:
1. Turns out he is a total chemo-flirt!
2.And, we’ll have to start taking his temperature. Not funny, you say? We’re going to have to do it rectally! I have a regular digital thermometer which can be used rectally. And yes! I do have the little thermometer covers (condoms?) to prevent germs (or poops in this case) from transferring mouth to butt, LOL!
Teardrops:
1. I was thinking about a wedding we have coming up in August and hoping that he will be here (even though we’ll have to send him to Mom’s for the trip.)
We have worked on a tentative budget and it is tough right now and will continue to be until these first two intense months are over. The following months are going to be spaced out more and will be easier to handle. I am so happy that we are able to do this for him- I realize that this is a luxury and not everyone with a pet who suffers from lymphoma is able to give them this opportunity, or sees fit to do so…I’m glad to have him around, doing so well.
Poodle took him. She will be the one who takes him to most of the appointments since she has a little more flexibility than I do with the job. Everything below is according to Poodle, typed by Jessica. We are also using this as a kind of diary and reference, so please be advised we will be mentioning puke, poop, pee, etc. where necessary.
He did so well in the car ride there, but was nervous in the waiting room…there were a lot of dogs around. Dr. Wall talked to Poodle about what side effects to expect from the drugs he was receiving today and gave us two prescriptions. The prednisone he’s been taking will be cut back, and he gets nausea meds for 4 days and if needed, has a diarrhea pill for future use. Apparently, the expectation is that there may be a small amount of vomiting. But any less than 2 ralphs is ok- more than two vomits call the vet. They only gave him an injection of vincristine today as the second drug was not in yet. He will get that one tomorrow. Poodle will be dropping him off tomorrow and whichever one of us gets off first will pick him up from the emergency vet side of the building.
After the Dr. talked to her, they took Atticus into the back to give him his injections.
Poodle said Atticus had a ‘pep in his step’ when the vet tech brought him from the back…she said he was lifting his paws up high and prancing the whole way out across the waiting area for all to see! All the nurses turned to admire him, they love him; the flirt. He now sports a purple bandage on his leg.
Poodle says he has been napping since then on the couch with a blanket. Dreaming of nurses I’m sure 
We have decided on the aggressive chemo for Atticus. His appointment is tomorrow morning. I am nervous and trying to be optimistic. Atticus had diarrhea with a little blood on Saturday night and I am hoping that won’t affect anything tomorrow. He has been fine since and nothing unusual as far as his BMs since that night.
I am having a slightly hard time being optimistic right now because I’m worried about the decision we made…is this the best thing to do for him, what if he has side effects like nausea or fever? I’m afraid I’ll get discouraged and want to quit…Then I think that I am all he has. I have to do what is best for him and be positive and make the best decisions.
I have been doing so much reading, talking to the vet, talking it all over with Peter and Krisann and sooo much thinking. Maybe too much thinking all day today about how he has been lately.
But today, Atticus is really doing well. He ate leftover catfood after his own dinner, slept with Krisann under the covers with the heating blanket on and has a good amount of energy. He has been feverish lately and refuses to be under any covers; hasn’t had enough of an appetite to eat much of anything so it is a super treat to see him act so normal. He is flipping out trying to get treats and being very snuggly.
So Krisann is off work and we are all sitting around discussing the options and what is best for Atticus.
Luckily, there is a veterinary oncologist locally who met with Krisann and I yesterday. Peter was unable to make the appointment and is having a more difficult time understanding why we want to go with chemo when there are therapies he read about online that will “cure” him. We have spent several hours discussing it and I am getting tired of arguing over this with him. Here are the facts:
Canine lymphoma is curable in less than 2% of dogs. Chemotherapy is viewed as the best treatment option for achieving remission. Remission does not mean a cure- it simply means that the tumors are unable to be detected, returning the dog to a pre-cancer state of being. The cancer will grow back and sometimes a dog can go into several remissions with chemo or combination therapies.
Chemotherapy in dogs is drastically different that what humans go through. Because the chemo is used only to achieve remission (not a cure) much less of the drug is used, resulting in only 5-10% of dogs having side effects. The side effects that those 5-10% go through are stomach upset, vomiting, diarrhea, etc.
Most dogs have a great quality of life and this is what we are hoping for with Atticus. The best two options (as our vet sees it) are an aggressive chemo regimen and a less aggressive chemo regimen. There was another even less aggressive chemotherapy regimen that they perform at the office as well as radiation but at this time, considering his stage and current health, these are not the best options.
I think we are strongly leaning towards the aggressive chemotherapy. It would involve a weekly appointment for injections or infusions of a combination of the most popular drugs for two months. The following four months would mean a visit to the office every other week for different combinations of the drugs.
To clarify, the vet tests his organ functions before giving the drugs each treatment to confirm exactly which drugs he can handle and which ones are doing the most. We discuss what his side effects have been and how he is doing in general. They will alter the treatment when needed or stop if he is not responding. We reevaluate constantly.
Peter really feels positive in the ability of radiation to cure Atticus so we have decided to go for the aggressive chemo and ask about adding radiation. The radiation is something the vet told me is not the best option for him now but Peter wants to be more aggressive so we’ve agreed to talk to her about it again.
Ultimately, we all want him to live with the best quality of life for as long as possible. Not a single one of us wants him to have to go through some drawn out, painful procedures, or suffer through months of nausea or diarrhea. That isn’t worth it for him and I would feel like a piece of shit for making him live longer just for my pleasure.
He is only 7.5 years old. No matter what we do his life is now limited by lymphoma and we will have to consider euthanasia at some point- sooner or later. We are going for chemo because putting him down now is depriving him of good, quality life that we have the ability to provide.
I adopted Atticus from Operation CARE in York SC sometime in April 2004. He was born the previous August. I had found him online at Petfinder.com and fell in love with his long legs and adorable face. The lady told me that he was a sweet little guy who slept in their bed, under the covers with them. As Mom and I drove the four hours back to her place in Charleston, Atticus grew nervous. He squirmed and snuggled up to me in the passenger seat. He shoves his head all the way into my right sleeve, his body wrapped around my chest and that is how we drove home.
He snuggled right into my heart that day and has stayed there ever since.
Being a new dog owner was hard for me initially. I wasn’t certain what he needed or how to treat him all the time but I loved him and over time I learned. He, thankfully, was smart enough to work with me and stay out of trouble on his own. He always slept under the covers, sat on my lap, excitedly welcomed me home whenever I came in the door.
He has been with me through some of the best and worst times, always waiting impatiently to cuddle up and love me for scratching his head and being a warm place to stay. When I was on and off again with an ex I spent countless hours crying onto him. He mirrored my enthusiasm anytime I was promoted at work or succeeded in making it through another day.
Mornings were rough before he came along, but with him, I slowly woke up to a nuzzling, lovey ball of fur rolling in the covers, trying to get me to scratch his back. He would finally follow me out of bed by dragging his body along the carpet, hind legs trailing behind. I said, “draggin’” when he did it and eventually he started doing it on command. “Draggin’”! I’d yell and he immediately drops to the floor and starts dragging his legs around. It still cracks me up.
When I went to Biloxi, MS after Hurricane Katrina for three months, he stayed with his Grandma in Charleston. He has spent weeks at Dad’s in PA where he enjoyed his Grampy’s massages and Wendy’s pampering. He used to enjoy napping on Grampa F’s comfortable lap, and warmed up next to Gram at night while watching tv. But he has also snapped at, bitten, charged at and practically torn a few family members apart. Not his best quality but we love him nonetheless.
He was my second pet after living on my own. We got Nico while in college and due to her unusual kittenhood, always had some social issues. It took her a while to come around but eventually gave in and at least put up with him. She went missing while Peter and I were on Christmas break in NY a couple years ago. I believe she is currently living with a retired couple who travel to Myrtle Beach in an RV.
His other animal friends include his girlfriend, Channing. Channing lives here in Charleston and the first time they met, she was a little puppy- half his size. A few months later, when we went to visit Mom again, he discovered she had more than doubled in size and towered over him! They ran and chased and tore the floors to shreds with their constant marathons. They barked and growled and played for the entire visit. His boss is in PA: Mickey. Mickey may be older but she sure doesn’t put up with his crap! She lets him think he has a chance to sit on Wendy’s coveted lap then kicks his tiny behind with a flick of her head leaving him dumbfounded.
Here at home, he now deals with four cats. Only Pablo plays with him. None of the others really give a care what he does.
He has always been in great health. Until Christmas 2010. We noticed a hacking, sometimes wheezing cough and after researching online, attributed it to kennel cough. His energy, appetite, and mood were completely normal. A few weeks later, when the cough wasn’t getting better, we took him to the vet who seemed, according to Peter, baffled by the symptoms and test results. By this time, his appetite dropped off significantly, followed by his weight. We were referred to a specialist in a neighboring town and set an appointment there as soon as we were able.
She noted his recently enlarged lymph nodes and some light colored masses in his chest and abdomen on the x-rays. Fluid samples are collected and sent to the lab for confirmation. She suspects lymphoma. To ease his breathing difficulty and generally help him out, she prescribes Prednisone and Pepcid.
After I get off work, Krisann sits me down on the couch to tell me the grim diagnosis. I completely lost it that night. Both of us cry uncontrollably and try to make sense of what is going on with him. Peter cooks and gives hugs; quiet and comforting.
Since then, the steroid has drastically reduced his symptoms. Prednisone induces complete remission but it lasts only up to two months so we need to decide if we want to pursue other options.
The specialist has referred us to a local oncologist. She is great and is so informative and understanding of our situation. There are a few options, including several types of chemotherapy, radiation, prednisone and no treatment at all. There is a large range in price, survival times, side effects, quality of life. This is what we are dealing with this weekend. We three, Peter, Krisann and myself, have tasked ourselves with making a decision on what the best course of action is to maintain his quality of life.
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