Thursday, April 16, 2009

"HEY!!!-- Break It Up, Break It Up!!!!"

That's what I heard Michael screaming this morning as Chandler instigated a bit of rough-housing play with Riley. That's right- not the other way around. Clearly Mr. Yorkie-turned-Chinese-Crested is feeling much better, and we couldn't be more thrilled. Still-- lots of wound healing to go and suture removal isn't until next Wednesday, so we need him to stay nice and calm-- no jumping or rough-housing. And the weather is spectacular here and going to be so for the next few day, so try to keep him from chasing squirels and such in the yard... this should be our only problem with him, right?

I just got off the phone with Dr. Rocha (Oncologist)and we reviewed Chandler's final pathology report of (totally benign) fibrosis in the urinary bladder- so that's nothing to treat. We also reviewed the pathology of the tumor and affected lymph node in the neck which were very positive for malignant melanoma, but also significant for a clear margin on both; implying that the whole cancer plus a small bit of the healthy surrounding tissue is out. We like to have clear margins in medicine because that implies that you got the whole tumor and a perimeter of healthy looking tissue that might not be healthy. Meaning, even though that perimeter looks normal the cancer may have spread into those cells on a microscopic level, but not to an extent that we can see it. Given the very fast and high rate of spread with malignant melanoma, this is how it comes back over and over again, and how it spreads to other organs/tissues so quickly.

Normally they like to get a 2 cm margin. However in oral cancers (even in larger breeds) that's anatomically restricted. In Chandler, they got a 3-4 mm margin. Still, because the adjacent lymph node is affected, he's an advanced Stage II. Dr. Rocha said that Chemotherapy is off the table and it doesn't work in dogs in melanoma.

So he presented us with the following options:

1) Do nothing at all. Avergage survival would be 3-6 more months with likely mets to the lymph nodes and/or lung.

2) Continue with the oral melanoma vaccine only (i.e., no radiation therapy.) Chandler received the first vaccine at surgery and will get the 2nd one next week. He will get two more, thereafter, for a total of 4 vaccines every 2 week. Then, assuming he responds and is well, he will continue with 6 month "boosters". Most dogs who respond will survive between 6 months and 1 yr on this. However, it's important to realize that not all dogs respond to this vaccine therapy.

3) Vaccine therapy with radiation of the primary oral site and radiation of the adjacent lymph node chain. At a cost of $8,000 - $9,000, raditaion will administered in 18 individual week day treatments (he gets Saturday and Sundays off). Statistically, this increases survival (if the dogs responds) to between 1 - 1 1/2 years. How it works? Well, Chandler will start to feel a burn at the end of week 1 and this will intensify progressively through weeks 2 and 3. The burn from the lymph nodes is said to be akin to a bad sunburn with local sensitivity and not much else. However, the oral burn, while better tolerated in larger breed dogs, is very poorly tolerated in small/toy breeds, like Chandler. Dr. Rocha said that by week two of therapy, expect a period of a minimum of 2 but (more likely) up to 4 wks of debilitating pain. This often results in the need to place a feeding tube as the dog can no longer swallow and it's agonizing. Often, they need to place it via the stomach as an NG (nasogastric) tube is physcially too irritating to the dog to tolerate going down into the stomach. I have to say, I really, really, REALLY pressed him for his opinion. He said that, in his experience, owners who have opted for oral radiation often are left (in the end) questioning, "Why did I put my baby through that?" I said, "Really?" And he said, "In my opinion, radiation of the oral cavity in small dogs is ethically highly questionable."

4) Vaccine therapy with radiation the adjacent lymph node chain, ONLY. Also the same cost of $8,000 - $9,000, raditaion is administered in same pattern of 18 individual week day treatments. This works the same as above-- just feels like a really bad sunburn and the skin needs to be tended with moisturizer, but it has NO EFFECT on appetite, level of activity or alertness, and even little dogs handle it well. If this works, it can potentially take hi survival to "better than 1 year", provided the non-irradiated primary oral tumor doesn't regrow (since we're not irradiating it.) Otherwise, that one spreads and then we're back in the 6 months range.

So... quite the questions here. Assuming the astronomical cost of this weren't a factor, it all seems like a big crap shoot in a 14 year old dog. We certainly have a LOT to talk about.

ONE MORE THING: We're putting this out here to help ourselves and others. We're trying to share information, in part, with the hope that someone else, somewhere else, someday whose beloved little angel also gets this horrible disease will have a resource into the present day treatment options and though process of pet-parents who are struggling with difficult issues. Michael and I request that you respect our privacy and not post opinons about treatment. This is a very personal process for us and our family and we need to come up with our own answers and options. Thank you.

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