so sorry for you and your loyal companion. i would think that if humans can survive without one then a dog could too. i guess it all comes down to the dx. hoping for the best.

Darn it ! I know the stress of something like this .
Several years ago my Dane's pancreas quit him , we tried everything to get him to eat , my HB. even baked him oatmeal cookies his favorite .
I am hoping for a good outcome for her . Hugs ... Gin

Thanks for your thoughts. Her liver function tests came back very abnormal, so a liver issue might be causing the enlarged spleen. Her WBC was normal so it's not a simple infection though.

I took her back to the vet today for IV fluids etc., and she'll spend the night. I finally got an appointment in the morning for an ultrasound and possible aspiration.

Thanks for the link Gin. I've read all kinds of stuff on the internet regarding combined spleen and liver issues and they aren't necessarily all bad.

However, since I work in oncology, all I can think about are worst case scenarios, especially with both the liver and spleen involved. I have this dreadful feeling I might not be bringing her home again after the ultrasound. If she has cancer, no point in letting her slowly starve to death unless prednisone or something can stimulate her appetite and keep her happy and comfortable for a few more weeks.

I just keep popping xanax when I start to think too much.

Remember when I said my bird Simon had a liver problem ? He was on Milk Thistle and Lactulose for a long time 2 drops 2 times a day .
I took him in last Wed. for a blood panel .. liver is normal .
She is lucky to have someone that cares ,and will do what is best . G

I've also used Milk Thistle for my cat with weird liver enzymes. It only took about 3 months on this for the liver panel to be near normal.

Laura, I hope everything works out nicely for you and the furry one...Do keep us posted.

Three days and $1000 later I have a diagnosis. My dog has lymphoma in her spleen, liver and enlarged lymph nodes throughout the abdomen. I guess of all the possible cancers, lymphoma is one of the "kinder" types of cancers. I was fairly certain she had cancer of some type and I was actually relieved to find out which she had. Of course, the prognosis is the same and she only has a few months at most.

From what I read (quickly, I didn't really research it)with no treatment she might have two months (she hasn't been eating so that's not even possible)with chemo she might have 10 or 11 months if it goes into remission and 70 to 80% of dogs given chemo for lymphoma do go into remission. The chemo would be for 14 weeks and even though it's not as hard on dogs as it is on people they can still suffer nausea, vomiting, diarrhea, lethargy etc. So if she spends 3 months feeling a little sick out of 10 possible extra months of survival, the net gain at best is 7 months. That's just not worth it.

All that aside, I'd never give a dog chemo anyway, especially one pushing 12 even though she has the energy of a 5 year old dog.

So, the vet was more than willing to go along with my idea of treating her with prednisone to try and stimulate her appetite and perk her up. Prednisone has the added benefit of quite often causing tumor regression or stabilizing growth and/or spread. Even best case scenario, she lives six months, she still won't live long enough to suffer the long term side effects of high dose steroids. (working in oncology is a double-edged sword, there was no doubt in my mind this was probably cancer, but I also have a sense of how to handle the situation and still be as kind as possible to the dog while assuaging the guilt I feel for letting her get cancer, regardless of how ridiculous that train of thought is but we all think like that).

She spent last night and most of today at the vets getting IV fluids etc and it did her a world of good.

I'VE GOTTEN HER TO EAT!!!!!!!!!!!!!!!!!!!!!!!!!

Okay it was just a couple of pieces of cheese and one had her prednisone pill in it, she also ate 2 dog treats. She got in a fight with the other dog over a piece of a treat laying on the floor so at least she is interested in food again.

I hope I have some warning if this progresses into her lungs, an enlarged node threatens to obstruct a vein or artery or her esophagus, although presently there are no palpable nodes in her head, neck, axillary areas etc. My gut instincts are going to have to get us through from here on out, as there are no particular protocols for monitoring cancer progression in dogs. I don't want her to suffer at all. I'm just trying to give her a couple more good months and me a chance to get used to the idea.

My sense is we will be okay for the first couple of months.

Hey Gin, glad to hear your bird's liver has returned to normal. That's not easy to correct in birds.

Canine Lymphoma
Canine lymphoma are rewarding to treat as long as a few secrets or rules are known. The following are a few important prognostic variables for canine lymphoma.

Clinical Stage:
IV + V worse than I-III
-dogs with clinical signs worse than if asymptomatic.
- Hypercalcemia: worse when associated with an anterior mediastinal mass.
- Sex: female dogs better than male dogs.
-Body size small dogs better than large dogs
- Pretreatment corticosteroids: worse.
- High grade: higher response rate and longer duration of remission.

When considering treatment, one must remember that the more complex the protocol, the longer the first remission, higher the cost and toxicity.

The following is a general overview of canine lymphoma.

Background
Malignant lymphoma (lymphosarcoma) is a lymphoproliferative tumor of solid lymphoid tissues with possible marrow metastasis and a leukemic phase. In dogs,
it accounts for 5-7% of all tumors seen and occurs at an incidence rate of 24 cases per 100,000 dogs. It occurs most commonly between 5 and 12 years of age. Boxers, Cocker Spaniels, Fox Terriers, German Shepherds, Scottish Terriers and Golden Retrievers are at an increased risk when compared with other breeds.

Etiology for the canine is unknown. In the cat, 90% of the cases are FeLV related
and it occurs at an incidence rate of 41.6 cases per 100,000 cats. This accounts for one third of all feline neoplasms and is two and one-half times the rate of lymphoid
neoplasia in man. There is a slight male>female predominance in cats.

Clinical Signs
The clinical presentation of canine malignant lymphoma is most commonly that of a multicentric nature with peripheral lymphadenopathy being the most striking
feature; however, any organ may be affected. In the cat alimentary involvement is the most common presentation.

Other anatomic presentations for both the dog and the cat include anterior mediastinal, cutaneous, and unclassified (e.g. mucocutaneous, CNS, renal) forms. Ocular involvement (anterior uveitis, hypopyon, hemorrhage, infiltrate) is seen in approximately 20-25% of canine casesof malignant lymphoma. Involvement of the spleen, liver, and bone marrow is common in both dogs and cats.

Diagnosis
Once clinical findings compatible with a diagnosis of malignant lymphoma have been found, aspiration and cytology of accessible lesions should be completed. Malignant lymphoma is characterized by the replacement of normal lymph nodes by a uniform population of pleomorphic and bizarre lymphocytes. After a tentative diagnosis of malignant lymphoma has been supported through rapid cytologic methods, confirmation of the diagnosis may be conducted by biopsy. A tissue core may
be obtained by Tru-Cut biopsy or, preferably, a node may be excised for final confirmation.

If a dog or cat is to undergo therapy, clinical staging is mandatory. Clinical staging determines the extent of disease in the living animal. Once a baseline of data has been obtained, the clinical oncologist will be able to know which parameters should be monitored in order to each complete remission. Clinical staging should include
radiography of the thorax and abdomen, a complete blood count and platelet count, a bone marrow aspirate and core, an ophthalmic exam, measurement of representative
enlarged lymph nodes and a biochemistry panel with special emphasis on calcium and protein levels.

Abnormal findings beyond lymphadenopathy are rare, however marrow infiltrate with subsequent release of cells into the peripheral blood is occasionally seen. Hypercalcemia associated with a parathyroid-hormone-like substance is observed in some dogs with malignant lymphoma. This is most often encountered in dogs with anterior mediastinal lymphoma and bone marrow involvement.

Prognostic Factors
Prognostic factors are difficult to confirm due to the variation from study to study. Most treatment reports indicate that hypercalcemia and poor performance status
are predictive of short remission and survival times. Animals with advanced clinical stages (World Health Organization Stage IV and V), or at least those with malignant cells in their bone marrows, are also considered to have a poorer prognosis than those animals with less to have a poorer prognosis than those animals with less
advanced clinical stages (WHO Stage I-III).

Some reports suggest that treatment with glucocorticoids prior to therapy with more aggressive chemotherapeutic agents cause a poorer response to therapy than seen in dogs which have not been treated with glucocorticoids, but this finding has not been consistently observed.

Histopathology
Considerable controversy exists regarding the value of histopathologic classification of canine malignant lymphoma in regards to prognostic criteria. The Rappaport
classification scheme is of little value because nearly all canine lymph node biopsies are classified as diffuse lymphocytic poorly differentiated, thus preventing subgroups of animals to be studied. The National Cancer Institute-Working Formulation (NCI-WF) allows biopsied tissues to be classified in several categories, but once again,
the vast majority of classifications fall within either the diffuse large cell or immunoblastic groups and no consistent differences have been observed in remission or survival times for dogs in these two subgroups. Classification in other categories of the NCI-WF might show predictability, but so few cases of canine malignant
lymphoma are classified in those categories that firm recommendations for pet owners based on these criteria is not possible.

Therapy
Treatment for malignant lymphoma must be systemic in nature since it is a multi-system disease. Chemotherapy is most frequently utilized; however, some
immunotherapy has been effective. Untreated, dogs affected with malignant lymphoma live an average of only six weeks once a diagnosis has been made. With
chemotherapy, dogs can survive for 6-10 months or more with an excellent quality of life. Dosage of chemotherapeutic agents for the cat is the same as for the dog except when Adriamycin is used. While dogs may receive Adriamycin every 21 days at a dosage of 30 mg /m2, cats appear to be more sensitive to the drug and many of them can only tolerate a dosage of 20 mg/m2 given every 21 days. Anorexia and renal failure have been reported as significant side effects in cats.

Malignant lymphoma is one of the most responsive forms of cancer presented to the practitioner.

With appropriate chemotherapy protocols, nearly 90% of animals placed on therapy should reach complete remission. Of those that reach remission, approximately
80-90% will maintain a reasonable (>6 mos) timeframe of excellent quality life. Cost is not inexpensive; however, it is within reasonable financial reach of many clients, thus allowing therapy to be possible. Although marginally effective, prednisone is
inexpensive and often used in combination with other drugs to treat lymphoma. With prednisone therapy, the average pet lives 2 months. One-third of the dogs and cats treated with prednisone will go into complete remission, one-third will go into partial remission, and one-third will not respond at all.

Adriamycin is one of the most effective single agent treatments for lymphoma in dogs. Of the dogs treated with adriamycin, 81% developed a complete and
partial remission. The duration of remission is approximately 9 months. Dogs treated with Adriamycin and then switched to COP (cyclophosphamide, oncovin,
prednisone) had a higher second remission rate compared to those started on COP and then switched to Adriamycin.

The COP protocol is effective for inducing a remission in 75% of dogs with lymphoma. A median duration of remission of 6 months is commonly seen. Approximately twenty percent of the dogs treated with the COP regimen are in remission at 1 year. In one study, 79% of cats with lymphoma treated with COP achieved a complete remission whereas only 29 percent of cats treated for lymphoblastic leukemia achieved a complete remission.

Cats with lymphoma treated with COP had a shorter remission time (64% achieved a complete remission, median remission 5 months) but proportionately more long-term,
survivors than dogs. Cats with renal lymphoma tend to have recurrence of tumor in the brain, therefore cytosine arabinoside is frequently recommended as an additional
therapy.

Thanks for all that info chickadeedeedee.

She did have an aspirate and the cytology was positive for lymphoma. From the best I can tell, she's a stage IIIB, the B because she stopped eating. Plain x-rays only showed the enlarged spleen but not the enlarged nodes. Although the spleen is enlarged, there didn't seem to be a mass in it, so I guess I can quit worrying about a major bleed.

If there was a chance for a remission or long term survival lasting a couple of years, I might take a chance with chemo, as I feel the dog would definitely live that long if it weren't for the lymphoma (being a dog, she wouldn't live long enough to suffer the long-term side effects that people can encounter, I'm guessing anyway). Her activity/energy level, blood counts, eye sight, hearing, kidney function etc., all belie her true age of almost 12, at least this was true until a few days ago. Her LFT's weren't all that abnormal and if I could find old records, they may even have been normal depending on her baseline. I didn't have any luck finding any old CBC's but I haven't checked with the local after hours clinic yet.

A remission or disease-free survival of a couple of years, doesn't seem to be possible, but if I'm wrong please let me know.

I don't think it's fair to her to spend, at best and it's a long shot at that, 12 months getting poked by needles, prodded and palpated, imaged, possible hospitalizations if she has a bad reaction or her counts bottom out (although I realize this not a frequent side effect of chemo with dogs), going the chemo route. Then there is the possibility of extravasation and amputation.

The canine oncology clinic here would give her Adriamycin, Cytoxan and doxorubicin, as well as prednisone. I inquired about rituximab (Rituxan), as that's a pretty standard treatment for some types of lymphoma in people, but they don't seem to give it to dogs.

My hope is the prednisone, if we are lucky, will give her two more months of chasing bunnies, squirrels, and the UPS man; squabbling with my other dog over whatever it is dogs squabble about; breaking into the neighbors yard to go swimming or harass the cats; sneaking across the street to go "creekin"; harassing the German sheppard across the street cause the sheppard is afraid of my 15 pound bundle of attitude; rides in the car etc. Maybe I'll even get to take her for a swim in the ocean one last time, she loves that.

This whole situation is just plain depressing.

Once her appetite improves (it has a little) and she perks up a little more, I'm going to try exercise as a way to also improve her quality of life and the amount of time she has left. It seems a lot of people with lymphoma seem to have a lot of luck with massive amounts of exercise. I'm not going to put the dog on a treadmill or anything but a mile or two of walking a day might help and it won't hurt any of us.

I'm interested in any and all info I can get, so keep it coming.

Thanks Laura

Hi again!

Here are a whole bunch of links to sites to help you find an oncologist or get more information so that you will feel as comfortable as possible with this situation and the decisions made for your pup.

http://www.avma.org
American Veterinary Medical Association

http://www.avma.org/education/abvs/vetspecialists.asp
Veterinary Internal Medicine Link

http://www.acvim.org
Veterinary Internal Medicine

http://www.acvim.org/Specialist/Search.aspx
Veterinary Internal Medicine/Oncologist Search Link
(let's you find an oncologist near you)

The truth is ... no matter the ultimate decision that you and your family make regarding your family member, PLEASE know that it will be THE RIGHT DECISION! You will have a lot of information and are able to make an intelligent decision based on the information about chemo or other options but more importantly based on what you know is best for your dog!

PLEASE let us know if we can do ANYTHING else for you !

Hope this has helped you at least a little! :-)

Please check. You have LOTS of mail from me about this subject. Notes from a veterinary oncology conference I attended. Every patient is different, be they human or animal. Generally with lymphoma tx. there is no diarrhea or vomiting associated with the treatment and after the initial induction the IV injections are but once a month for most protocols.

Kindest regards to you and yours,

C with 3 Ds

Hi again.

I tried to send you another e mail but GW has issues right now with that ability so I'll just post a bit of info. for you. My vet oncologist had said that many patients have an average survival of 1-2 years but several are doing well 5 years and beyond! As with everything the individual patient responds in their own unique way.

Here is some more of what I have specifically for K-9 lymphoma and some other stuff that may help. I have about 7 other e mails worth of relevant chemo information too but for now here goes:

COP Therapy Protocol for Dogs and Cats

Cytoxan 250 PO
Vincristine 0.75 IV
Prednisone * 30 P O
* Prednisone is given daily for the first 21 days, then every other day thereafter. Note that maintenance is continued on a 3 week
schedule for at least 1 year.

The addition of adriamycin to the COP regiment resulted in longer remission time (7 months vs 6 months). A complete remission was attained in eighty-four percent of dogs treated with COPA. An additional 7% achieved a partial remission. Twenty-two percent of dogs treated with the COPA protocol were in remission at one year.

COPA protocol for Dogs Cytoxan 250 PO Adriamycin \* 30 IV Vincristine 0.75 I V Prednisone \*\* 30 P O \+ This protocol can be used in cats if the dosage of adriamycin is reduced to 15\-20 mg/m 2 . \* Adriamycin is given every other treatment during the maintenance phase for a total accumulative dosage for a total accumulative dosage of 250 mg/m 2 . \*\* Prednisone is given daily for the first 21 days, then every other day thereafter. The addition of L\-Asparaginase to the COP protocol increased the duration of remission, and the toxicity. The use of this protocol resulted in a complete remission in 76% of the dogs treated. The median duration of remission was 11 months with 48% still in remission at 1 year. Thirty\-seven percent of the dogs treated with this protocol developed toxicoses (vomiting, diarrhea, depression, anorexia). Twenty\-nine percent were sick enough to require hospitalization. The bottom line is that the more drugs are added to the protocol, the longer the remission and the more the toxicoses.

ACOPA protocol for Dogs

Cytoxan 250 PO
Adriamycin * 30 IV
Asparaginase 10,000 U/m 2
Vincristine 0.75 I V
Prednisone ** 30 P O
+ This protocol can be used in cats if the dosage of adriamycin is reduced to 15-20 mg/m 2 .
* Adriamycin is given every other treatment during the maintenance phase for a total accumulative dosage for a total accumulative dosage of 250 mg/m 2 .
** Prednisone is given daily for the first 21 days, then every other day thereafter.
Note that the maintenance phase of the protocol is continued for a minimum of 1 year.

University of Wisconsin Protocol for Dogs Cytoxan IV 200 mg/m 2 Adriamycin IV 30 mg/m 2 Vincristine IV 0.5\-0.7mg/m 2 Asparaginase IP 400 U/kg MethotrexateIV 0.8 mg/kg Chlorambucil PO 1.4 mg/kg Prednisone PO mg/kg Daily: 2 1.5 1 0.5 \+ On week 19, continue as above (weeks 11\-17) every 2 weeks, alternating adriamycin and methotrexate. Upon reaching the maximum cumulative dose of adriamycin (180 mg/m 2 ), stop doxorubicin and continue with methotrexate. After week 25, treatments can be given every 3 weeks. After week 49, treatments can be given every 4 weeks. Chemotherapy is stopped at 3 years. Another protocol involves administering adriamycin at 30 mg/m2 body surface area q3 weeks for 5 treatments as long as the dog stays in remission. One day after the first adriamycin therapy, l\-asparaginase is administered IM weekly for 3 treatments (10,000 Units/m2). When the patient comes out of remission, then COP therapy is started as mentioned above. The duration of remission 1 plus remission 2 is similar the the COPA protocol noted above with less toxicity and less cost to the client. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Cancer is one of the most common diseases in dogs and cats in the United States, Western Europe and Japan. Cancer cachexia is the most common paraneoplastic syndrome in veterinary medicine. This paraneoplastic syndrome of dogs and cats with a wide variety of malignancies results in profound alterations in carbohydrate, protein and lipid metabolism that subsequently results in anorexia, fatigue, impaired immune function, poor performance and weight loss in the face of adequate nutritional intake. These profound alterations in carbohydrate, protein and lipid metabolism have been documented in dogs and probably in cats with cancer, even before evidence of cancer cachexia was clinically apparent. The importance of cancer cachexia is underscored by the knowledge that animals and people with cancer cachexia have a decreased quality of life, poor response to treatment, and a shortened survival time when compared to those with neoplastic diseases but do not exhibit clinical or biochemical signs associated with this condition. Therefore, it is obvious that cancer and cancer cachexia are of tremendous importance to the practicing veterinarian. Nutritional therapy is a key component for the treatment of cancer cachexia and for actually helping control malignant disease in some situations. Specific nutrients can be used as powerful tools to reduce toxicity associated with chemotherapy, radiation therapy, and is important to enhance healing subsequent to surgery. There is little question that nutritional intervention must begin early and must be followed through aggressively to gain maximum benefit?..long before the patient exhibits evidence of weight loss, debilitation, or anorexia begin which can in turn enhance response to therapy and improve quality of life. The purpose of this article is to answer the following questions: 1\. What clinically significant alterations in metabolism occur in animals with cancer cachexia? 2\. How can knowledge about the metabolic alterations in metabolism change the way you use nutrition to treat your cancer. In other words: what nutrients should you feed your cancer patient? 3\. Does surgery, chemotherapy or cancer increase or decrease the energy needs and the amount you should feed your patient? 4\. Are there any data on the efficacy of the nutrients my clients constantly ask me about: vitamins, minerals, proteases, garlic, tea and shark cartilage? 5\. What are the indications for intervening aggressively with appetite stimulants, tube feeding or total parenteral feeding for your cancer patients? 6\. When and how do I place these feeding tubes in my practice? Metabolic Changes Associated with Cancer Cachexia Clinically, in many patients there are three phases associated with cancer cachexia. The first phase is the preclinical "silent" phase is where the patient is not exhibiting any clinical signs of disease, yet there is evidence of biochemical changes such as hyperlactatemia, hyperinsulinemia and alterations in amino acid and lipid profiles. All of these alterations are of impending clinical importance, but the alterations in carbohydrate metabolism appear to be quite profound resulting in the production of tremendous amounts of lactate through energy inefficient anaerobic metabolism. The second phase is the clinical phase where the patient begins to exhibit weight loss, anorexia, lethargy and early evidence of weight loss. These patients are more likely to exhibit side effects associated with chemotherapy, radiation therapy, immune modulation, and surgery. Cancer Cachexia Alters Carbohydrate,Protein, and Lipid Metabolism ³ Occurs in All Cancers! Occurs in All Cancers! ³ ³ Occurs Early Occurs Early ³ ³ Decreases Quality of Life! The third and final phase of cancer cachexia is an accentuated form of the second phase; it is associated with marked debilitation, weakness and biochemical evidence of negative nitrogen balance that is also associated with clinical pathologic changes such as hypoalbuminemia.Cancer patients begin to loose carbohydrate and protein stores within the body. Loss of fat depots is the noted in this third and final stage of the disease. These patients literally waste away due to the physical effects of the malignancy and the resulting cancer\-induced alterations in metabolism. Carbohydrate Metabolism: Perhaps the most dramatic alterations in metabolism of animals with a wide variety of cancers occur in carbohydrate metabolism. For example, when dogs with a wide variety of malignancies without clinical evidence of cachexia were evaluated with an intravenous glucose tolerance test, lactate and insulin concentrations were significantly higher when compared to controls. The hyperlactatemia and hyperinsulinemia did not improve when these dogs were rendered free of all clinical evidence of cancer with either chemotherapy or surgery.Metabolic alterations result in part because tumors preferentially metabolize glucose for energy by anaerobic glycolysis forming lactate as an end product.The animal must then expend necessary energy via ?futile cycling? to convert lactate to glucose by the Cori cycle. The inability of some tumor bearing animals to tolerate glucose parenterally may have some bearing on the dietary management of the cancer patient. Logically, it can be concluded that diets high in simple carbohydrates may increase the total amount of lactate produced and the need for the host to utilize energy unwisely for conversion of lactate. This may have long\-term detrimental effects on animals with cancer. To test this hypothesis in the dog, a group of dogs with lymphoma were evaluated to determine if a diet high in simple carbohydrates is detrimental compared to a diet low in simple carbohydrates.In this study, dogs were randomized and fed isocaloric amounts of either a high fat diet, or a high carbohydrate diet before and after remission was attained with up to 5 dosages of doxorubicin chemotherapy. As hypothesized, the mean lactate and insulin levels from the dogs fed the high carbohydrate diet was significantly higher than the level from the dogs fed the fat diet after the dogs were fed the diets and put into remission with chemotherapy. Interestingly, dogs fed the high fat diet were more likely to go into remission. This study showed, therefore, that diet was effective for influencing response to therapy and select aspects of carbohydrate metabolism. The bottom line is that simple carbohydrates may not be ideal for the cancer patient. Therefore, when considering a diet for a pet with cancer, a diet that has minimal amounts of simple carbohydrates may be ideal. Protein Metabolism: Cancer has been shown to result in decreased body muscle mass, skeletal protein synthesis, and alter nitrogen balance while concurrently increasing skeletal protein breakdown, liver protein synthesis, and whole body protein synthesis. Tumors preferentially use protein for energy at the expense of the host. Tumors preferentially utilize certain amino acids for gluconeogenesis, which results in abnormal amino acid profiles. These abnormal profiles have been documented in pet animals with a wide variety of cancers. The use of amino acids by the tumor for energy becomes clinically significant for the host when protein degradation and loss exceed synthesis. This can result in alterations in many important bodily functions such as immune response, gastrointestinal function and surgical healing. Knowledge that cancer preferentially utilizes amino acids and that some amino acids may be therapeutic may be of value when designing a diet for the cancer patient. Providing high quality amino acids or protein in the diet may be of critical importance for the veterinary cancer patient. A quality protein diet that is highly bioavailable may be ideal. Arginine, glycine, cystine and glutamine may be of specific value for therapeutic purposes. Arginine may stimulate lymphocyte blastogenesis. The addition of arginine to total parenteral nutrition solutions has been shown to decrease tumor growth and metastatic rate in some rodent systems.Some amino acids my decrease toxicity associated with chemotherapy. For example, glycine has been shown to reduce cisplatin\-induced nephrotoxicity. Cystine has been shown to be effective for reducing Heinz body anemia in cats. Glutamine has been shown to be effective for reducing histologic and clinical evidence of methotrexate\-induced gastrointestinal toxicity in cats. Cancer: Anaerobic Metabolism Cancer: ³ Cancer Competes with Patient for Proteins ?Excess: Cancer Growth ?Deficit: Host Depletion The bottom line is that a diet that has moderate amounts of highly bioavailable protein may be of value to the cancer patient. Certain amino acids such as glutamine, cystine, and arginine may also be beneficial for some cancer patients. Lipid Metabolism: Fat loss accounts for the majority of weight loss occurring in cancer cachexia. Therefore, it is not surprising that human beings and animals with cancer have dramatic abnormalities in lipid metabolism. The decreased lipogenesis and increased lipolysis observed in humans and rodents with cancer cachexia result in increased levels of free fatty acids, very low density lipoproteins, triglycerides, plasma lipoproteins, and hormone dependent lipoprotein lipase activity, while levels of endothelial derived lipoprotein lipase decrease. Recently lipid profiles in dogs with a lymphoma were studied. It was determined that many of the alterations seen in other species with cancer were also present in dogs. These abnormalities did not normalize when clinical remission is obtained. The clinical significance of these abnormal lipid profiles in dogs with lymphoma is not known, however, abnormalities in lipid metabolism have been linked to a number of clinical problems including immunosuppression which correlates with decreased survival in affected humans. The clinical impact of the abnormalities in lipid metabolism may be lessened with dietary therapy. In contrast to carbohydrates and proteins, some tumor cells have difficulty utilizing lipid as a fuel source while host issues continue to oxidize lipids for energy.This has led to the hypothesis that diets relatively high in fat may be of benefit to the animal with cancer when compared to a diet high in simple carbohydrates. Further research may reveal that the type of fat, rather than the amount, may be of greater importance. In one study, mean nitrogen intake, nitrogen balance, in vitro lymphocyte mitogenesis, time for wound healing, the prevalence of wound complications, and the duration of hospitalization was significantly better in 85 surgical patients fed an omega\-3 fatty acid supplement when compared to controls. Studies of polyunsaturated fatty acids (PUFA's) of the n\-3 series, especially eicosapentaenoic (EPA) and docosahexaenoic acid (DHA), indicate that these fatty acids may prevent the development of carcinogen\-induced tumors, the growth of solid tumors, as well as the occurrence of cachexia and metastatic disease in experimental tumor models. Fatty acids of the n\-3 series have been shown to normalize elevated blood lactic acid and insulin levels in non\-malignant conditions . In contrast, PUFA's of the n\-6 series appear to enhance tumor development and metastases. These data, along with the epidemiological findings of an inverse relationship between dietary n\-3 fatty acid intake and incidence of some cancer, is the basis of research to evaluate the potential benefit of n\-3 fatty acids in the prevention of cancer cachexia and therapy of malignancy in cancer patients. One such study was recently completed in dogs with lymphoma. A double blind, randomized study was recently reported to evaluate the hypothesis that polyunsaturated n\-3 fatty acids and arginine can improve metabolic parameters, decrease chemical indices of inflammation, enhance quality of life, and extend disease\-free interval and survival time in dogs treated for lymphoma. In that study, dogs fed the experimental diet had significantly higher serum levels of polyunsaturated n\-3 fatty acids docosahexaenoic acid (C22:6) and eicosapentaenoic acid (C20:5) as well as arginine when compared to controls. Both diets were formulated to be relatively low in simple carbohydrates, with moderate amounts of highly bioavailable proteins. This formulation is designed to enhance the effect of n\-3 fatty acids. Higher serum levels of these n\-3 fatty acids were associated with lesser plasma lactic acid responses to intravenous glucose and diet tolerance testing. Increasing C22:6 levels was significantly associated with longer disease free interval and survival time for dogs with stage III lymphoma fed the experimental diet. Another study was recently completed that was designed to determine the effect of a diet supplemented with n\-3 fatty acids and arginine on irradiated skin and oral mucosa, carbohydrate metabolism and quality of life in a group of dogs with nasal tumors.This study showed that fatty acids of the n\-3 series normalize elevated blood lactic acid. In a dose dependent manner, n\-3 fatty acids result in decreased histologic evidence of radiation damage to skin and mucosa and improve performance scores in dogs with malignant nasal tumors. This would obviously be of great benefit to the cancer patient receiving radiation therapy. These two studies confirm that diets supplemented with polyunsaturated n\-3 fatty acids are of benefit for the cancer patient. The bottom line is that n\-3 fatty acids in moderate amounts appear to benefit the cancer patient. More specifically, a diet relatively high in n\-3 fatty acids and relatively now in simple carbohydrates has been shown not only to improve alterations in metabolism associated with cancer, but also improve response to chemotherapy and decrease the adverse effects associated with radiation therapy. Fiber Soluble and insoluble fiber are both important to prevent cancer and to enhance bowel function. This can be especially important for the cancer patient that may undergo chemotherapy, radiation therapy and surgery. Fats Cancer Cannot Use Fats ?93% Tumor Derived ?Fats Last to be Depleted Fiber is important not only to treat disorders of the gastrointestinal tract, but also to prevent concurrent diseases such as clostridial colitis. Therefore, a diet with adequate amounts of soluble and insoluble fiber may be indicated for many dogs and cats with cancer. The data noted above suggest that a diet relatively low in simple carbohydrates, with moderate amounts of highly bioavailable proteins as well as soluble and insoluble fiber, and moderate amounts of polyunsaturated fatty acids of the n\-3 series may be of value to the cancer patient. Research is needed to address the issue of optimum quantities of carbohydrates, proteins and fats, especially n\-3 fatty acids. In addition, the ideal ratio of n\-3 fatty acids to n\-6 fatty acids also remains an unknown. The ideal diet is made of much more than carbohydrates, proteins and fats. A brief discussion about some of what is known about vitamins, minerals and other ingredients is listed below. Vitamins, Minerals, Garlic, Tea, Shark Cartilage and the Cancer Patient: Nutrients such as vitamins, minerals, garlic, diet\-generated protease inhibitors, tea and shark cartilage have been suspected as being important for the prevention, control and treatment of malignancies for decades, and in some cases, generations. This field of study is poorly documented with controlled studies, but is rapidly evolving into mature science that may improve the quality and quantity of life for human and animal patients with cancer. The news media and lay publications often distort or misinterpret the efficacy of vitamin therapy. While it is naive to believe that a single nutrient or set of nutrients will be effective for the treatment of cancer there is optimism to believe that one or more nutrients can be effective for preventing certain types of malignancies in people and in animals. Most veterinarians are asked by their clients if vitamins, minerals, garlic and other nutrients can be beneficial for their pet with cancer. Below are a few examples of nutrients and a few situations where they have been shown to have preventative or therapeutic effects. Because there are very few studies in veterinary medicine, studies involving rodents or human cancer patients will be used as models for veterinary disease. While it is not possible to make solid recommendations from these data, it may be adequate to allow the veterinarian to provide some guidance to their clients about these nutrients. Vitamins: Retinoids, beta carotene and vitamins C, D and E may influence the growth and metastasis of cancer cells via a variety of mechanisms.These vitamins fall into and out of popularity based on the results of select studies and the lay press. The weight of the literature would suggest, however, that many of these vitamins may be of value for some cancer patients. A few of many select examples of the impact of a few vitamins is included below for the interested reader. Retinoids: Retinoids are not used as a mainstay of cancer therapy, however there is a growing body of knowledge about the anticancer effect of this vitamin in man and animals. In people, 13\-cis retinoic acid prevents secondary tumors in patients treated for squamous cell carcinoma of the head and neck and can reverse the effects of cervical human papillomavirus infection. Retinoic acid when used in the adjuvant treatment of retinoblastoma (a childhood cancer), resulted in translocation of bound receptor vitamin complexes to the nucleus, which results in the regulation of the neuroblastoma gene.Melanoma in mice has been successfully treated with retinoids. The efficacy of retinoids is not confined to rodents and people. A study was recently completed to evaluate the synthetic retinoid isotretinoin and etretinate to treat dogs with intracutaneous cornifying epithelioma (ICE), other benign skin neoplasia, and cutaneous lymphoma. All tumors were diagnosed by histologic examination. Successful treatment with isotretinoin was achieved in dogs with ICE, inverted papillomas, and with epidermal cysts. Successful treatment was achieved with etretinate in dogs with ICE. In addition, remission was achieved in 6 of 14 dogs with cutaneous lymphoma. Adverse effects developed in about 25% of the dogs. Vitamin C: Vitamin C has been studied continuously over the last several decades as an antioxidant and an agent that can effectively treat conditions such as colds, cardiovascular disease and cancer. There have been some data that vitamin C may be of value for the prevention and treatment of certain types of cancers. Water\-solublevitamin C has been widely reported to inhibit nitrosation reactions and prevent chemical induction of cancers of the esophagus and stomach.Processed foods high in nitrates and nitrites, such as bacon and sausage, are often supplemented with vitamin C to reduce the carcinogenic capability of the resultant nitrosamines. A human tissue culture subline resistant to vincristine that was established from a small cell lung cancer cell line was pretreated with ascorbic acid, resulted in potentiation of the vincristine effects on resistant but ascorbic acid may be one therapeutic alternative for overcoming a drug resistance in some cancer cells. Vitamin E: Lipid\-soluble vitamin E, or alpha tocopherol, can also inhibit nitrosation reactions, but in addition, vitamin E has a broad capacity to inhibit mammary tumor car\-cinogenesis and colon carcinogenesis in rodents. In addition to its chemopreventative properties, vitamin E may convey potential therapeutic efficacy against certain malignancies. This vitamin does so due to its antiproliferative activity. In the study conducted in cooperation between the Comparative Oncology Unit at Colorado State University and the Harvard School of Public Health, Department of Dental Medicine, was done to evaluate the effect of injecting d,l\-alpha tocopherol and beta carotene directly into dogs with a variety of oral malignancies. A total of 12 dogs were entered into the study where they received weekly injections of this combination to result in mediation of tumor cell growth. This study resulted in two dogs achieving a complete remission (50% reduction in the original size of the tumor\-\-both soft tissue sarcomas) and minor reduction in tumor size in two other cases. There was no direct evidence of tumor cytolysis in this study. Additional studies have been initiated in humans at Harvard School of Public Health. Additional studies are essential to allow further clarification of the value of these vitamins. Minerals: Minerals that have been suggested as having chemopreventative or anti\-cancer effects and that are of value as nutrients include selenium, copper, zinc, magnesium, calcium, lead, iron, potassium, sodium, arsenic, iodine and germanium. Selenium has been one of the most heavily studied minerals associated with the development of cancer. Low serum selenium levelshave been seen in human patients with prostate and gastrointestinal cancer. In rodents, dietary supplementation of selenium has been shown to inhibit colon, mammary gland and stomach carcinogenesis. An additional study is essential to determine whether alteration of selenium levels would be of value for the treatment of veterinary or human cancer patients. Iron transferrin and ferritin have been linked to cancer risk and cancer cell growth. Lung cancer, colon, bladder and esophageal cancer in people has been highly correlated with increased serum iron and increased transferrin saturation. This may be because many tumor cells require iron for growth. Therapeutic enzymes: Enzymes have therapeutic potential although imited approval in the United States. L\-asparaginase is probably the most valuable therapeutic modality for the treatment of lymphoma and leukemia in animals and people. Oral enzyme preparations are used for the treatment of chronic pancreatic insufficiency and disaccharidase deficiency. Several enzyme preparations are available in Europe for oral adjuvant treatment of cancer and other diseases. Of those, Wobenzyme and Musal, contain a similar mixture of enzymes. Recent studies report efficacy for the treatment of cancer patients, the mechanism of which is not precisely known. One hypothesis is that these enzymes eliminate pathogenic immune complexes. Therefore, enzymes may indeed be of value for the adjuvant treatment of cancer. Protease inhibitors: There is a great deal of information that suggests that soybean\-derived Bowman\-Birk inhibitor (BBI) can inhibit or suppress carcinogenesis both in vivo and in vitro.Extracts of the Bowman\-Birk inhibitor have been shown to inhibit carcinogenesis in several animal model systems, including colon\- and liver\-induced carcinogenesis in mice, anthracene\-induced cheek pouch carcinogenesis in hamsters, and lung tumorigenesis in mice and esophageal carcinogenesis in rats.Bowman\-Birk inhibitor concentration has been shown to inhibit metastasis and weight loss associated with radiation\-induce thymic lymphoma in mice. Irradiated rodents treated with dietary Bowman\-Birk inhibitor concentration have fewer deaths, lower average grade of lymphoma, and larger fat stores than controls. Therefore, this protease inhibitor from soybeans may be an important adjunct to cancer chemotherapy protocols and to prevent secondary cancers. Epidemiological studies have suggested a correlation between high garlic consumption and reduced risk of cancer development.Each garlic extract and several garlics and thioalkyl compounds have been shown to inhibit the activation of carcinogens and the bonding of polyarene thiol epoxide to a DNA bases, which caused DNA lesions and initiates chemically\-induced carcinogenic process. Garlic and the thioalkyl compounds inhibit carcinogen\-induced aberrations in the cell nucleus. In addition, garlic extracts have an anti\-promotion effect in animals exposed to carcinogens. Also, garlic exerts direct cytolytic effects against cancer cultured human breast cancer cells and human melanoma cells. Concentrations of garlic used in these studies to arrest cancer cell growth, there is no effect on normal cells. Pretreatment of animals with garlic protects rodents against subsequent induction of tumors by a variety of carcinogens. There are no studies demonstrating the safety and efficacy of garlic for the prevention or treatment of cancer in people or in veterinary medicine. Science Diet n/d by Rx has the anti cancer ingredients within the formulation and is the only diet I know of comercially available, known to aid in the treatment of lymphoma. Hope this bit of info helps you and yours, :\-) C3D

I am so sorry, Laura~
She's a lucky girl to have you.
You KNOW I'll be praying about it.

Wow, you've left my head spinning. Thanks for all the info. I'm going to print it all out, follow your links, and research it all further.

At the very least, I need to put her on the Science Diet n/d. I feed SD maintenance anyway. She also drinks ice tea, so using tea as an antioxidant is very easy for us to do.

My email address that had been listed at GW is no longer any good. I did just change it to a new one but my main email box is my GW user name at gmail.com.

I think once I research this further I should make an appointment with an actual canine oncologist and/or call NC State to talk to one of their oncologists or have her seen for a consultation at NC State. Maybe they have some new protocols. The local specialty clinic doesn't have a canine oncologist per se but treats the dogs through the internal medicine department. They do have a canine radiation oncologist though. Unfortunately, NC State's veterinary clinic is a good 150 mile round trip so treating her there isn't really feasible.

Thanks again

Laura

Hello yet again! Lot's of reading, ehh?

As a plan of cancer treatment (either for cure or control/management) is being developed and initiated, there are three commandments of cancer care that must be adhered to and followed. These three commandments are a direct response to the caregiver's three greatest concerns about what cancer care may look like.

The first Commandment: Don't let them Hurt!

Providing active preemptive and ongoing pain management for the cancer patient is absolutely imperative, and will reassure the caregiver that quality of life is optimal. This can be in the form of oral medications (sustained release morphine, codeine, feldene, carprofen or others) or transdermal delivery systems for fentanyl. The most important principle is that our caregivers know in advance that the veterinary health care team will not tolerate any pain during any phase of therapy and that we will all work together to recognize, prevent and manage it.

Comprehensive management of pain involves careful evaluation and treatment of each cat and dog. Adequate pain control must be the highest goal for the veterinary practitioner to maximize quality of life, response to therapy and survival time. Pain control in veterinary medicine has only recently come into the forefront of attention, primarily because of the inappropriate attitudes of clinicians, lack of knowledge about analgesic medications, and lack of skill in assessing pain and appropriate therapeutic methods. In many cases, analgesics have been withheld because of fear of adverse side effects of these drugs and because very little research exists demonstrating the beneficial effects of pain relief in veterinary patients. Despite this, pain relief is and must be one of the very highest goals of the entire veterinary health care team.

Recent research has demonstrated that once pain is elicited, there is a magnification of the pain response. This is termed the wind up phenomenon. Therefore, when compared to "on demand" therapy, the preemptive and judicious use of analgesics, including the fentanyl patch is more likely to increase patient comfort, decrease need for hospitalization and subsequent expense, and reduce the amount of pain medication used to achieve the same level of comfort. Therefore, whenever possible, preventative therapy should be utilized rather than to try to suppress the pain once it becomes a clinical problem. To prevent side effects, in the event of surgery, the fentanyl patch may be more appropriately placed post-operatively.

The fentanyl patch will result in slow warming postoperatively. In order to preempt pain, it is imperative that fentanyl be administered parenterally during surgical procedures. This may be accomplished by intravenous constant rate infusion. And then during the immediate post operative period application of the patch may be accomplished. The management of pain does not only depend on pharmacologic manipulation, it truly begins with good quality compassionate care.

Careful nursing with gentle handling of the patient and the provision of an environment that is comfortable and relaxing is of great benefit. Local anesthesia should be employed whenever possible to alleviate local discomfort. Systemic analgesia should be employed whenever there is a possibility that discomfort is not localized or adequately controlled with local analgesia.

Mild Pain: The treatment of mild pain with regular doses of aspirin, or nonsteroidal anti-inflammatory drugs (in cats Tylenol must not be utilized, and aspirin must only be used with caution) may be quite effective. These drugs do not cause central nervous system toxicity because they work peripherally. However, these analgesics can cause gastrointestinal upset. Although they are quite effective, they are not perceived by owners as having a significant analgesic effect and therefore may be dismissed as useful drugs.

Fentenyl patches are not indicated for these patients with mild pain.

Moderate and Severe Pain: Moderate pain can be treated with at least one of the nonsteroidal anti-inflammatory agents such as aspirin. However, this level of analgesia may fail to meet the needs of the patient. Opiate analgesic agents such as fentanyl are often used for moderate pain because they have peripheral as well as central analgesic effects. If moderate to severe pain is not relieved with either nonsteroidal agents or opiate analgesics when these drugs are given individually, then combining analgesics for pain relief can certainly be considered. Additive toxicity must be monitored. If this is not effective, then adjuvant therapy for the malignancy itself may be indicated.

For example, radiation therapy to bone pain sites may be of profound benefit. In addition, administration of analgesics by another route, for example, switching from subcutaneous to intravenous administration may be effective. Sustained release morphine (1-2 mg/kg BID) may also be helpful in some cases. Nerve blocks or other surgical procedures to alleviate discomfort can also be employed.

The transdermal fentanyl patch (Duragesic, Janssen Pharmaceutica, Titusville, NJ) is a relatively new device that has practically revolutionized pain control in cancer patients. Since its release, the use of morphine pumps has declined. The patch boasts ease of use, portability, flexible dosing, and efficacy. Side effects are generally minimal, or easily managed. Duragesic is indicated for chronic pain in dogs and cats with moderate to severe pain, requiring constant analgesia. The active ingredient, Fentanyl citrate, is approximately 75 times more potent than morphine while producing fewer histaminic side effects. Patches are available in strengths of 25 (cat and small dog), 50 (medium sized dog), 75 (big dog), and 100 (giant breed dog) mcg per hour. Due to the size of cats, only a 25 mcg per hour size is recommended. These patches have a 72 hour duration of action. This infrequent dosing schedule allows the owners and veterinarian to attend to matters other than pain control; if applied correctly the drug will be delivered in effective doses and fewer dosing units in the house removes much of the problem of co-habitant abuse, (when this is an issue.) Duragesic's disadvantages include a lag period of 8-12 hours before peak levels are achieved. Also, typical opioid negative effects can be seen. Treatment of overdose consists of removing the patch and administering a naloxone bolus followed by a carefully monitored naloxone drip. Obviously, this sort of intervention is best avoided altogether; proper and careful dosing and titration is the key.

The Second Commandment: Don't Let Them Vomit!

This commandment strikes at that overlying unfounded fear that animals on chemotherapy will experience extreme amounts of nausea. This is just not true. Cancer care has advanced recently such that nausea and vomiting are uncommon problems associated with chemotherapy. We have the tools to control this problem. Dispensing oral medication such as metaclopramide with a client each and every time a potentially nauseating drug is administered empowers the caregiver to prevent this symptom at home. In addition, we must be prepared to stop vomiting if it should occur and that medications and supportive care be immediately available if that were to happen.

Stocking drugs such as ondansetron (Zofran) or dolasetron (Anzemet), although costly, will provide this level of assurance for all members of the team. In addition to antinausea medication, the dehydration caused by any significant vomiting or lack of water intake must be treated. Fluid therapy, should be administered in patients that are dehydrated. Deficits secondary to dehydration should be replaced during the first 24 hours. Maintenance fluid needs should also be administered and are approximately 66 ml/kg/day. Continued losses such as vomiting and diarrhea should be estimated and replaced.

As noted above, potassium chloride should be supplemented to the fluids if hypokalemia is identified. Potassium should not be administered at a rate greater than 0.5 mEq/kg/hr because to do so may result in cardiac arrest and death. The patient should be monitored for fluid overload using the following parameters: body weight, capillary refill time, skin turgor, chest auscultation, packed cell volume, total solids and central venous pressure. As normal hydration is reestablished it is important to stop any subsequent nausea with parenteral administration of antiemetic agents. In addition, all nausea/vomiting may NOT be chemotherapy induced. It is vital to also recheck the patient for underlying diseases (pancreatitis, renal failure, etc) and treat the inciting cause of the nausea as well.

Antiemetic agents (to control vomiting / emesis)

Metaclopramide. In veterinary medicine, metoclopramide (Reglan) is one of the most commonly administered antemetics. It has both central and peripheral antiemetic effects. Metoclopramide is a dopamine antagonist that blocks the chemotactic trigger zone and prevents emesis through this central mechanism. In addition metoclopramide increases the tone of the caudal esophageal sphincter and increases gastric antral contractions by relaxing the pylorus and duodenum.

Metoclopramide can be given at a dosage of 0.2 to 0.4 mg/kg intramuscularly or subcutaneously every eight hours, or at dosages of 1 to 2 mg/kg as a constant rate infusion over a 24 hour period by an intravenous pump. Metoclopramide may also be dispensed at the time of chemotherapy administration as an oral medication to stop or prevent mild chemotherapy induced nausea/vomiting.

Phenothiazines. Phenothiazines (eg. chlorpromazine, prochlorperazine) are commonly used as antiemetics for mild chemotherapy-induced nausea. In human medicine,phenothiazines are generally not effective for reducing efferent impulses due to severe gastrointestinal irritation. They block the chemotactic trigger zone of the emetic center. These drugs can induce vasodilation and therefore should not be used in dehydrated patients or those with poor cardiac output. In addition, phenothiazines can induce mild depression and make patient monitoring difficult. All phenothiazines can induce seizures in predisposed animals. Chlorpromazine can be
administered at 0.5 mg/kg IM or SQ every 6 to 8 hours and prochlorperazine can be dosed at 0.1 to 0.5 mg/kg IM or SQ every 6 to 8 hours. In suppository form (Compazine, SmithKlineBeecham) is available and can be administered to appropriate patients (none of the cats I know!).

Narcotic Analgesic. Butorphanol (0.4 mg/kg) has been suggested by some as a drug to reduce the prevalence of vomiting in response to the administration of chemotherapy. The drug also has analgesic properties. Its efficacy is minimal.

Antihistamines. Antihistamines (eg. diphenhydramine, dimenhydrinate, trimethobenzamide) are another class of antiemetics. They block input from the vestibular system and work against motion sickness-induced vomiting.Diphenhydramine can be dosed at 2-4 mg/kg every 8 hours and can induce mild sedation.

Serotonin Antagonists. Drugs that inhibit the 5-HT-3 (5-hydroxytryptamine) receptor are an entirely new and effective form of antiemetics. Ondansetron (Zofran) or Dolasetron (Anzamet) are currently available and other similar agents are being explored in human and veterinary cancer patients. Serotonin antagonists are effective for reducing chemotherappy-induced vomiting. They induce less toxicity than metoclopramide. Ondansetron, Dolasetron and other serotonin antagonists are expensive when compared to other traditional anti nausea medication, however they are much more effective, and in a crisis situation may be the most appropriate option for therapy.

Ondansetron is a selective 5-HT3 receptor antagonist. While ondansetron's mechanism of action has not been fully characterized, it is not a dopamine-receptor antagonist. Serotonin receptors of the 5-HT3 type are present both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone of the area postrema. It is not certain whether ondansetron's antiemetic action in chemotherapy-induced emesis is mediated centrally, peripherally, or in both sites. However, cytotoxic chemotherapy appears to be associated with release of serotonin from the enterochromaffin cells of the small intestine. In humans, urinary 5-HIAA (5-hydroxyindoleacetic acid) excretion increases after cisplatin administration in parallel with the onset of emesis. The released serotonin may stimulate the vagal afferents through the 5-HT3 receptors and initiate the vomiting reflex.

The dose of ondansetron (Zofran) is 0.3 mg/kgIV q 12 hours.

The dose of dolasetron(Anzemet) is 1 mg/kg IV 1 24 hours.

Both drugs may be combined with constant rate infusion of metaclopramide in the event of intractable vomiting.

The Third Commandment

Don't Let them Starve!

Finally the last commandment: Don't let them starve IS just as vital. In the minds of many caregivers, patients undergoing cancer care often appear cachectic and weak. Today we have the benefit of years of research into the metabolic alterations of cancer and the ability to counteract them nutritionally. In addition, using the team approach and providing care that assures our patients do eat is vitally important.

This includes basic nursing care (warming food, providing aromatic foods and comfortable environments) medicinal appetite stimulants and finally assisted feeding techniques such as esophagostomy tube placement. All of these components of nutritional care must be available early in the course of disease, and weight loss must not be tolerated. To our caregivers, appetite is a vital objective assessment of quality of life that must not be overlooked or left to chance. In addition, caregivers know that nutrition is vital to life, but it also is one method by which they may provide care that has no potential for harm. They intuitively know that nutrition is vital to quantity of life, but when they are empowered to know that nutrition may actually affect the results of the other forms of therapy, they realize an even more vital role in the treatment of their beloved pet.

The term cancer cachexia as a clinical entity is defined as weight loss in the face of adequate nutrition resulting from metabolic alterations that occur prior to any clinical evidence of weight loss or debilitation. It is the most prevalent of all paraneoplastic disorders, and is thought to be present universally in all cancer patients regardless of whether it is clinically evident or not. The ideal method of addressing cancer cachexia is to eliminate the underlying neoplastic condition, however, this is often not possible and efforts to provide nutritional support become important. In addition, recent studies have shown that the metabolic alterations of cancer that result in clinical as well as preclinical cancer cachexia are present early in the disease process and persist even after the cancer has been removed surgically or placed into complete remission with
chemotherapy.

Specific recommendations for nutritional support of patients with neoplastic disease should be based on estimates of caloric requirements, the patient' s current and past
nutritional status, and a knowledge of the underlying disease as well as the metabolic changes specific to cancer. Enteral feeding should always be considered first: if the gut works, use it! While there are many physiologic and medical reasons why nutritional therapy should begin early, there are also psychological reasons. Clients bring their pets to you because they love them. Most are eager to become part of the health care team to be part of the process of bringing their beloved friend to health while extending love and affection to their pet. This interaction can enhance quality of
life for both the patient and the client. Below is a brief review of applied interventional nutrition therapy.

Enteral dietary therapy has been shown to be a practical, cost-effective, physiologic, and safe modality that may abate or eliminate cancer cachexia, decrease complications from therapy and actually improve response to therapy. Several studies have failed to document the possibility of increasing tumor growth by enhancing the nutritional status of the host. The dogma is that mature dogs and cats with a functional gastrointestinal tract that have a history of inadequate nutritional intake for 3-7 days or have lost at least 10% of their body weight over a 1-2 week period of time are candidates for enteral nutritional therapy. There is no question that this philosophy is short sighted. Nutritional intervention must begin earlier than these guidelines suggest. The key is to prevent weight loss or even appetite decline long before they occur.

How to Enhance Appetite
³ Megesterol Acetate
0.25-0.5 mg/kg q24hrs Q 3-5 days, then q 48-72 hrs

As a general rule, mature dogs and cats with cancer with functional GI tracts that require nutritional support should have some form of enteral feeding: If the gut works, use it!!! The first step is to enhance appetite. The owner should be given a short term and long range plan for the nutritional support of their pet. This plan allows the veterinary health care team and the owner to have a sequential plan for maintaining nutritional support by first enhancing appetite, second, using tube support in appropriate cases, and third, considering more advanced measures such as total parenteral nutrition for serious problems. The first step, enhancing appetite, begins with the basics: warming the food to just below body temperature; providing a selection of palatable, aromatic foods; and providing comfortable, stress-free surroundings. When these simple procedures fail, such chemical stimulants as benzodiazepine derivatives (e.g., diazepam and oxazepam) and antiserotonin agents (cyproheptadine and pizotifen) can be used.

Cyproheptadine (2-4 mg daily or twice daily PO) generally is effective in stimulating appetite in cats, as are megestrol acetate (0.25mg daily for 4 days, then every 2?3 days thereafter). These drugs can be used concurrentlyfor maximal stimulation of the appetite.

Diazepam (0.050.5 mg/kg IV) is great for short term therapy in the hospital, but is often not adequate for home therapy.

Dogs and cats may have improved appetite when metoclopramide is given orally to decrease nausea associated with chemotherapy or surgery. When all the aforementioned fails, enteral nutritional support via a jejunostomy,esophagostomy,
gastrostomy or jejunostomy tube feeding, designed to deliver nutrients to the GI tract should be considered because it is practical, cost-effective, physiologic, and safe.

Enteral Feeding Methods

The type of nutrients to be used depends largely on the enteral tube that is used and on the status of the patient. The big question is: what should you feed the cancer
patient? The easy answer is, whatever the pet will eat, however, specific therapy is preferred.

Blended canned pet foods may be adequate for feeding by esophagostomy and gastrostomy tubes. Whenever possible, consider diets that are relatively low in simple carbohydrates, easily digestible, and that have appropriate soluble and insoluble sources of fiber. The later can be accomplished by adding psyllium to a canned maintenance pet food diet or by using Hills nd with psyllium. Because the latter has restricted calories, an increased volume of feeding may be needed. Human enteral feeding products are easily administered though nasogastric and jejunostomy tubes (eg: Impact, Osmolite HN, Jevity), however, veterinary enteral products are now available that are specifically tailored for the nutritional needs of animals, especially cats (eg: Clinicare). In any case, feeding usually is not started until 24 hours after the tube is placed except for pets with an esophagostomy tube.

Once feeding is started, the amount of nutrients is gradually increased over several days and is administered frequently in small amounts, which allows the animal to adapt to this method of feeding. Continuous feeding may reduce the risk of vomiting caused by overloading the GI tract. Regardless, the tube should be aspirated 3 to 4 times a day to ensure there is not excessive residual volume in the GI tract. The tube should be flushed periodically with warm water to prevent clogging.

Once the philosophy and mindset of cancer care is embraced and a team is built, compassionate care of the cancer patient becomes a vivid reality. The cancer patient is cared for as well as the needs and concerns of the caregiver, in a nurturing environment that will not only provide the best science can provide for the patient, but an atmosphere of healing and hope for both the patient and the caregiver. The
medical needs are met, the patient and the tumor is adequately assessed and evaluated, options for care are examined and evaluated, a treatment plan is selected and the care then begins. The overall goal of this cohesive team is ensuring quality of life for a precious family member, there is no doubt that quantity of life will also be the reality.

It is at this place that the veterinary health care team is most effective and most successful. The goal and the reality becomes the victory of achieving moments of time for a caregiver to share with that most precious pet that they have entrusted within our care, the reality and victorious outcome is moments of the bond.

I DO NOT ever post such detailed information on the Internet forums but I thought this was important for you and your family and I can't do this off forum with you. The nice thing about K\-9 or Feline lymphoma is that is does NOT appear to be a painful condition. They just feel crummy. In most patients with lymphoma chemo, the dogs and cats, they do not experience vomiting or diarrhea like people will. If you consult with a board certified vet. oncologist they will know what is best for your situation. These are just general guidelines and information. All needs to be customized to the individual patient. As you may know, cancer treatment is not inexpensive. You can look into a service called: Care Credit which will allow treatments to happen with a low interest credit. Hope this additional info helps too. C3D

.........Yep, one more time until I leave GW forums for a while.

I sent the following link to you as an e mail, but you did not get it. So here is a thread detailing my own ordeal with canine cancer. It was hemangiosarcoma of the spleen. An Entirely different entity with which to cope but this was our story.

Kindest regards and the best of luck with your loved one!

C3D

Thank you so much for all the info. I'm glad your dog has survived cancer and treatment so well. That's no small feat.

Do you know what I'm most kicking myself in the butt about now? Being so stingy with "people" food and my vegetarian phases. And not eating snacks.

I have no idea what to try and feed my dog that she won't say no to. I know she likes steak and McDonald cheeseburgers, as well as sausage, bacon and eggs but that's about it. The dogs don't even like fries. Of course usually gravy and grease go over well on the very rare occasion they get it on their food (Thanksgiving and Christmas when everyone is trying to kill themselves with cholesterol). She will eat chicken livers but years ago when I had her in obedience, I tried to use dried cow liver as treats during training and she wouldn't eat that. I guess since I don't give them much in the way of people food (I don't like cleaning up the messes it can cause, besides the health issues)and I have the attitude of eat or so be it, my guys just eat for sustenance and aren't chow hounds.

Would you be surprised to learn that under stress, I become anorexic? That's one reason my dog has gone 2 weeks (jeez 3 now) weeks without eating. The first week I was stressed and not eating and, typically, she doesn't eat when I'm wound up.

I'm hating this right now. Don't get me wrong, they normally beg but the 1/4 x 1/4 inch piece of food they get isn't enough to make them obnoxious or overly desirous of whatever I'm eating. I don't snack very often, so I have no idea if they like chips or popcorn. Sometimes they will eat fruit. If course they love pizza, I guess I should call Domino's and see if she will eat that(the delivery person or the pizza?!). My dogs won't even drink beer, how strange is that? Most dogs love beer.

My dog gets prednisone every other day so today/Friday is her second dose. If she is not eating on her own by early next week, I feel it's time to let her go before she suffers. Right now she's either uncomfortable (pretty sure of it, she can't seem to lie on her right side) or just depressed. At any rate, regardless of how much I'd like to see her have a few more good months, if that's not possible, well, so be it. Tube feeding a dog doesn't work for me, but I would be willing to add a supplement to her water (in that respect the prednisone is working, I've got water bowls all over the house and they get emptied quick).

She will not suffer an instant of pain (I let a horse go too long once, that will never happen again with one of my pets). I just wish I had a crystal ball.

Listen to your inner feelings they will tell you what needs to be done and when .
Laura , it is not what she has not had , we tried everything with the Dane , cookies , steak , tuna , and about anything else I could name, he was used to getting a bit of what we had,people food , snacks , you name it .
Would eat none of it , at this point the kindest thing was for (us) to let go .
Hugs.... Gin

I've gotten her to eat this weekend. Yippee. Steak and chicken and some dog treats. Fortunately, she's not fussy about the quality of the steak. She doesn't eat on a consistent basis but at least I'm getting something in her. Friday night she pigged out, or would have if I had let her. After not eating much of anything for a couple of weeks, I was hesitant to give her too much. I was so happy when she finally ate, actually came into the kitchen and begged for my dinner, that I cooked dinner twice Friday night. She seemed perky and I felt she might eat a second time, and she did. She didn't eat at all Saturday, though, and most of Sunday but last night I got her to eat chicken and some steak and by god, this morning she even ate a little. Talk about doing a happy dance. The neighbors are even trying to get her to eat. Yesterday afternoon I was about ready to put her down just for my own sanity.

Thanks for all your thoughts. Laura

Sheesh....sorry to hear this...I've been in the wilds of Montana...Something which Luna loves, and she may just be wierd, but rice with some chicken stock (home made) and/or cottage cheese sometimes is a favored food which she will eat if nothing else will tempt her...but then Luna's a wierd one too. Salmon is one of her favorite treats. Keep us posted. I hope she does well. What a bite.

Thanks all for your insight, thoughts and help.

After a week on prednisone, she has only had a marginal improvement. Not enough to even ask if increasing the dose would be beneficial.

About 8 to 10 hours after I give her prednisone she will finally eat something, either steak or chicken, but that's all she will eat until the next dose (trust me, I've tried everything, well, except baby food. My dogs wouldn't go for the raw diet, I've found that out too). She only gets pred every other day, which is typical maintenance dosing.

She perks up here and there but for the most part acts like a dog would when they are outside and it's 100 degrees in the shade (but she's inside and cheap me has turned the AC down to 78, just for her, but she still prefers the basement under the fan or outside under the truck in the dirt). She's not in pain, but she's not comfortable.

I had hoped to buy her a little more time, but that doesn't seem to be in the cards. I'm just thankful that this disease stayed hidden as long as it did. It's only been 2 and a half weeks since it was really obvious something was wrong because she wouldn't eat. The first 5 days or so, I was upset about something and when I'm upset, she usually doesn't eat. Even this past Saturday I had to go across the street and get her out of the creek, because she had wondered over there and didn't have the energy to come home, but at least she had the energy to get that far and the desire to do it.

Human oncologists refer to this as "actively dying" when a patient quits eating, etc. I knew before she was even DX that was what was probably what was going on, although, of course, I had no idea why.

I just wish the next step wasn't so damn hard.

This is her, on the left, less than 2 months ago. At that time, if someone had told me we'd be facing this now, I'd have said they were a liar.

{{gwi:134818}}

She's nothing special to anyone but me and Paul and she's had a good life, even with an oaf of a Keeshond as a "brother".

Laura

What do you mean she isn't special? My daughter would happily do in Luna in order to have a sweetie like that! She wants a lap dog who has a lot of fur.... I feel for you. Having had to put down my old cat, I really can empathize....you just wish that someone would make the decision for you, or that they would just go gently.

I've thought about it for me, and I think I would want to have someone put me down if I were in a similar spot....too bad it isn't as easy for humans either to make the decision or to have it done. I hope that your baby is able to go as Tassie did...in my arms to the end...and she was purring as her tired old body went to sleep for the last time.

PS The oaf is cute too!

Thanks Lis.

Yes, I held her, won't have done it any other way.

Paul and I are going to spread her ashes on New Smyrna beach as she loved to swim there (she looks like a lap dog but she was a tom boy, the "oaf" is the lap dog, all 50 pounds of him).

They ask so little of us and give so much but in the end we have to pay it all back, ten-fold it seems.

Laura I am so sorry.
Nothing I can say will ease the pain .
Only time can do that . Hugs Gin :'(

My heartfelt condolences, Laura. It's so hard to let them go even though you know it's the right thing to do. I'm in a similar situation with my 40 year old donkey. The old man has outlived his poor old body and I'm wrestiling with the decision whether I should have him put down before the cold weather comes or wait and see if he does okay with his warm blanket, cozy stall and anti inflammatories for a while. I'm having the vet out to work on his teeth next week. We'll see if he has any ideas..................

so, sooo sorry..
darling pic of them.

Laura, I rarely visit over here and your story broke my heart. I share your saddness having lost 3 of my sweet babies in the past 4 years. My kitty was almost 17 yrs when he died last month. I lost my last sweet Rottie, Brie this April. She was almost 12 and had bone cancer. Every dog I've ever had died from cancer.
I just wish they would find a way prevent and treat this disease to extend the lives of our pets. They are taken so young.
C3D, your articles were so informative, I wish I had read them when I was going through this with my 3 dogs and cat.
Laura, I think you did the right thing. She didn't suffer.
Again, my heart goes out to you.

Jane

I'm so sorry to hear about that, Laura. As everyone has said, sounds like you did the right thing, but it is really hard. Stacy