My little girl

[barbikaras]

My little Mercedes has been diagnosed with lymphoma recently. I am struggling with the decision of giving chemo a try. With the help of some steroids, her condition is stable at the moment, but I know this will not last. I ask her what she wants to do, but she doesn't answer. She just looks at me with her beautiful green eyes and purrs. I am asking for a miracle.

[Tambrey]

prayers for Mercedes...and for you...

[Traci]

How old is Mercedes? What is your vet telling you? What has he recommended? Where is the lymphoma located, and was chemo and/or surgery recommended as an option? If so, are you declining for some reason, and for what reasons? Have you sought a second opinion?

Is Mercedes a kitty or dog?

If you have questions about treatment and chemo, I'd be happy to help answer questions you might have, but a history and current information on Mercedes from you would be helpful....

[barbikaras]

Thank you for your prayers, Tambrey. We need them.

[barbikaras]

Dear Traci,

Thank you for caring and for your inquiry.

Little Mercedes will be 9 on Aug 15; feline. (A beauty of a silver and black tiger . . . and otherwise known as Missy Moo)

The mass is in her abdomen - about the size of a baseball - entangled in the small intestine. I noticed that she had dropped some weight and her behavior/habits had changed. She's a feral - so, maybe not so warm and fuzzy that behavior changes are easy to peg.

She's had an x-ray, ultrasound, needle aspirates, and bloodwork. Abnormal labs are elevated Ca, eosinophils, platelets, and thyroid. Lymphoblastic lymphoma of the alimentary tract is our sentence. She's got some lymph nodes that are up, too, as detected by the ultrasound - which is expected.

I went for a consult with a feline onc - he's telling me that this type of tumor is the most responsive to chemo, particularly in felines. He explained it as the rule of thirds: 1/3 don't respond; 1/3 respond with good quality of life; 1/3 do exceptionally well and go on for 2 years or more. He said side effects, when the present, occur in about 10% of patients. Hmmm - that sounded a bit optimistic, particularly in light of the many horror stories I have encountered in a little over a week. The ultrasonographer and local vet state the tumor is inoperable, but the onc said debulking is indicated. I have declined this until we know that she will be in the two-thirds of cats that respond. One of my cats, who is waiting for me at the bridge, went through tumor debulking for a sarcoma that grew in the connective tissue - I will not put Mercedes through anything like that until I know if she has a shot with the chemo.

A week ago, she had a dose of long-acting Depo-Medrol, which seems to have given her some relief. And the appetite - it makes me laugh as I cannot keep enough food in the house! Her brother Angelico (literally, they are litter mates) sticks by her side - and thanks her for the extra food.

I did schedule the chemo for the upcoming Friday - I do not know the protocol yet, but will be speaking with the administering onc on Monday. I am nervous for a number of reasons, and was surprised when they told me I had to leave her for the day for observation following administration of the first treatment. Being a feral, trips to the vet are extremely upsetting for her - and this will be a 40-minute ride. I think that quality of life for her must take into account what she will be put through with the trips to the vet - and also what happens to her when she is there. It took her 3 days to recover from having spent an overnight for an ultrasound following her bloodwork and x-ray. The onc assures me that they grow accustomed to it and the trauma decreases . . . maybe I just need Valium.

That's about all the info I have at the moment - I will still turn this over in my mind until Friday comes. I have already signaled to the vet's office that I reserve the right to cancel - which they apparently are accustomed to.

Any advice you would care to offer would certainly be welcomed.

Warm regards,

bk

[Traci]

Thank you for the detailed information!

In palliative care (that is, symptomatic care, without invasive procedures), prednisone, a corticosteroid, is often prescribed to help "shrink" the tumor, and surgery may be more helpful when a tumor is shrunk. Prednisone also is helpful to increase appetite, decrease inflammation, etc. Depending on when the last xray was done, a new one might reveal the tumor might have shrunk, in which surgery might provide a better margin for removal.

Intestinal surgery is not without risk, but in this day and age, there are many many vets with competence and confidence in this surgery and most have done this several times. It is true that surgery to remove as clean a margin as possible of the tumor, followed by chemotherapy is the best approach in a large percentage of cats, particularly if the cat is otherwise in good health, does not have secondary health conditions, is a good candidate for anesthesia, and that good care is given directly after surgery and post-op care. Surgery is also not without risk, particularly post-op recovery, but it sounds like the oncologist is confident.

Chemo does not affect pets as it does humans. All the side effects you hear about chemo in humans rarely occur in pets. It is not without side effects however, but your vet (I assume) and oncologist are familiar with these, and will treat as necessary (or will cease chemo if a problem occurs). Each protocol is different for each patient, tailored to their needs and according to the type of tumor that is hoped to achieve remission or non-reocurrance. Your vet and oncologist would explain the process in greater detail and answer any questions you have. If the oncologist is confident surgery and chemo is the best option, it sounds like he has confidence in his ability and experience and you should talk to him in greater detail so you know just what to expect. If you are using both the oncologist and your vet in Mercedes' treatment, they need to work together and both should be available to you for questions, concerns, etc. Make a mental note to get numbers for both vets in the event you are concerned about something and need to talk to one or both in a timely manner.

The reason she would stay during the day after treatment to monitor, is because this truly is the best course of action after a chemo session. The vet wants to monitor the injection site, her attitude and appetite, observe for any reactions, like vomiting, etc, in which he could address and correct right then and there. He is probably also taking into account the distance you would be driving, since if you took her home directly after a chemo session and if she for some reason, had a reaction, it would be difficult for you to get back to the vet in reasonable time, especially if the vet does not have emergency or overnight services. A competent, caring vet wants the opportunity to monitor their chemo patients so they can provide them the best care possible and to allow the patient to be stress-free, limiting stress, keeping a calm and quiet environment, etc.

If the thyroid is going untreated, this could lead to some complications, please discuss that in detail with your vet, and of course, before Mercedes is considered for surgery. The vet might want to manage her on medications before surgery to at least get the thyroid under control and be less of a risk.

Cats are surprisingly resilient and tolerate the vet/office/treatment fairly well, despite our reservations. I personally commend the oncologist/vet for wanting to have Mercedes monitored for a day after chemo, and this should be a relief for you. It's better to have her in good spirits, good health, good response to chemo and released only when her health status is optimal, than to have you take her home too soon and she starts vomiting, or not eating, or there is a reaction at the injection site and you have no emergency vet available to you. However, you can certainly ask for the earliest morning appointment available and ask if they would consider releasing her in the early afternoon.

While difficult, and based on your experience, try not to equate this with your other rainbow kitty. The two cancers are different, act differently, respond to treatment differently. Ask both your vet and the oncologist what they would do if Mercedes was their kitty, I think you'll be surprised. It does matter greatly that you have a confidence level in your veterinary team, and if they are telling you this is a good option and expect a favorable outcome, I would, personally, heed the advice.

I know that cancer and chemo are scary, I do have alot of experience with this, both personally and in the clinic setting. I personally feel that when an oncologist is optimistic and has confidence in his diagnosis and treatment recommendations, and has the experience and knowledge behind him, and if the patient is otherwise in good health, etc, it's worth a shot to provide quality of life, extension of life, etc. I wouldn't want to give you false hope or say there are no failures in this treatment, but it is individual and there is truly no way to predict the outcome unless you attempt to treat. Please know there are "rescue" protocols available as well should a side-effect occur, and there are numerous symptomatic care approaches that can help the patient even further, such as proper nutritional support, medications to alleviate nausea or vomiting or diarrhea, etc.

I'm keeping Mercedes in my thoughts and prayers and want you to know you're not alone.....(((HUGS))).....post updates if you can, or even if you have other questions...

[barbikaras]

Thanks so very much, Traci.

I was not too impressed with the local vet, but she knows that I am considering pursuing chemo. Her words were those of finality, in a way - so, there is not a lot coming from there. The onc is well-known in Jersey - it's where we are all sent when we need a consult! He will be managing her case - but, Mercedes will receive her care at their sister hospital that is 20 miles closer to my home. The consulting onc told me which doc to use at the sister hospital and they have already discussed her case. Already knowing the potential for infiltrates if there is leakage of chemo outside the vasculature - I'd rather go to folks who do this everyday and, as you say, who know what to do if there are problems. I will make sure, though, that the local vet knows what's going on, and probably the emergency clinic that is just a few minutes away - in case I need help.

My challenge to initiating treatment with surgery was accepted by the onc; he agreed that it was a rational approach. If there is no possibility for chemo to get her in remission or reduce the tumor, there is no point of the surgery. The onc was more than confident in his recommendation basically not to "condemn her yet." I challenged him to convince me - beyond reasonable doubt - that chemo should be tried. He gave me much hope and was able to convince me - in fact, I think he thought I was nuts NOT to try, considering the type of cancer. As time passes, however, and as we learn more, we always have doubts.

When I look at her little face, it tears me apart to know that things could go badly. And that is the big question mark. But, I am asking for a miracle - and maybe the miracle I get is kind people like you to give support, reassurance, and lots of information to keep me on the right track for her recovery. I really do appreciate it and I will keep you updated. For now, we will concentrate on keeping her strong - I get great pleasure out of seeing her eat so good. I think she has actually put on a little weight since the steroid last week. She still gets around fine - when she wants to move around - but, she rests most of the time. She stays in my bedroom always (instead of coming downstairs) - where she is surrounded by 3 cat perches, 2 cat beds, and a partridge in a pear tree (ha ha). She still runs to and from the litter box and takes flying jumps onto my bed from the floor. (I have provided her with a step, just in case). These are good signs, I think, of her overall condition; however, although pain is not apparent (and I do know this look in a cat), I believe she has some ill feeling all the time.

We will enjoy our time this weekend . . . I get to hug and kiss her whenever I want now - which was previously a violation of her space, being feral and all. you know how they can be. Now she seems to expect it and not mind at all - which is very important for me.

Thank you again. I hope to be in touch soon with some good news.

bk

[Traci]

I understand very well how apprehensive you are, and how nervous you are. These are normal emotions, and I would have to question if you DIDN'T have those concerns.

Ultimately, it has to be a choice you make armed with information, and to some degree, high expectations, it sounds like your oncologist has alot of that for you! It is NOT an easy decision, but the what-if's should not prohibit you from making these choices, because the what-ifs will drive you insane and will not enable you to think clearly when Mercedes needs you most.

I had no reservations when I chose chemo for one of my little girls, I felt I had no choice, it was chemo with hope, or no chemo with certain demise. In her case, we did have a complication, and had to cease chemo, but please do not let this one testament prevent you from persuing it. Of course I was scared and out of my mind with worry, but I had to do something to try to save my little girl, as I knew she was not ready to leave me at that point in time, she gave every indication she was otherwise healthy, and enjoyed life, I couldn't take that away from her without giving chemo a try. In any other situation, it probably would have worked, but this particular tumor activity didn't respond, it was agressive. But, I would do it again if I felt it was worth it.

The most important part of chemo and treatment is staying in constant contact with your oncologist or your normal vet, it's crucial that communication is effective, that the vets are available to you when you have questions and concerns, and that needs are met at the first sign additional (symptomatic) treatment may be needed. Most pets respond to chemo very well and have no side effects at all, others have mild effects that can be treated quickly with supportive care. Vomiting, nausea, anorexia and diarrhea are the most common side-effects and those can be remedied quickly with supportive care (proper nutrition, hydration support, anti-nausea meds, etc). The hardest part is weekly sessions (depending on the protocol) and weekly CBC's, but necessary. I find that advising owners in keeping a daily log on their pets' routines, eating/drinking/elimination and overall attitude and activity helps to keep a clear head and is also helpful to inform your vet if you're concerned about something. If there were to be any changes, no matter how slight, in appetite, behavior, routine, etc, of course you would want to make contact with your vet immediately.

Don't be afraid to call your oncologist if possible, and keep asking questions if you have them. It's possible you DO just need reassurance, and other than here, your oncologist is best for that. Again, I don't intend to paint a rosy picture of chemo, because just as in every other form of treatment, there are risks, but I think you understand those risks and I think you are going into this with a level head, understanding, and a clear desire to help your little girl. I think she senses that too, and she's very fortunate to have such a good mom looking out for her.

I agree with the oncologist in combining surgery with chemo, you then have two advantages against this intestinal lymphoma as opposed to palliative care alone. If wide and clean margins are done, and the resection is successful, chemo can only be more beneficial in the majority of cases. I just want you to be prepared surgery is tough but many cats pull through effortlessly, and it sounds like your oncologist is comitted to her and her utmost care.

Keep us updated, and kiss your little girl for me, it sounds like she is just precious!