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Out of Remission?
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An_254554 posted:
Hi

My almost-7 year old was diagnosed with Stage 4 Lymphoma last March. We found out he had t-cell, and managed the funds to have a go at chemo. He took very well to it, and was clinically in remission after the second treatment at the end of March. He completed chemo in August and was clean on the scan of his spleen (it was covered in cancer). The only incident was after his last round of chemo with CCNU, his white cell count was literally 1, and he had to stay overnight at the hospital with a fever of 105.7.

At the end of September, the oncologists noted that his lymph nodes were swollen and they recommended another go with chemo and gave us a few days to decide. They did an in-house cytology and saw lymphoma, but when we returned we asked them to do the cytology and send it out. However, his lymph nodes had shrunk since then.

He is on prednisone now, and his lymph nodes were back to being larger. His oncologists said they were large, but could be worse. When we asked about getting lab work and another cytology, they told me that doing so could result in false positives and it would be hard to gauge his actual health due to the prednisone. He isn't showing any of the signs he does when he's sick or when he was first diagnosed: his energy is normal, he is eating fine and hasn't lost any weight that wasn't intentional (we pushed him to eat so much because we didn't see him eating that he gained almost 8 pounds in a month! Turns out he and his siblings had been snacking on each other's bowls when we weren't looking.) But his lymph nodes are still enlarged.

What would be the next course of action? I don't want to put him through chemo again, nor can we really afford a second go right away. Plus, the two options given to us were doxyrubicin, which I know from working with human oncology patients can lead to heart problems, and a combo of doxy and CCNU, the one that got him very sick. He is also past due for a physical at his regular vet, so I could have them do only bloodwork and physical on him to at least give me some data, but don't know what good that would do.

How long should I wait? I don't want to lose my buddy.
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AMERICAN VETERINARY MEDICAL ASSOCIATION
Sandy Willis, DVM, DACVIM responded:
Hi, Thanks for writing in and your excellent history.
It appears that you have worked very closely with your oncologists and your doggie did indeed go into remission, but is not out of remission. To clarify your concerns: Are you interested in doing the cytology at a diagnostic laboratory to confirm that the lymphosarcoma is back, essentially confirming what your oncologists saw, and in doing blood work to see how the rest of your dog's systems are doing? If so, with the lymph nodes now being large again, despite the treatment with prednisone, we may get a diagnostic cytology sample and yes, I think it is worth the procedure and the monies. And we generally do blood work prior to chemotherapy, A few parameters might be changed by the prednisone but I feel it a valid test. However, what I do know is that this is the time to consider the best chemotherapy option and being it without waiting too long. Prednisone alone can kill bad lymphocytes but it is more palliative than a true rescue chemotherapy. And your oncologists would be the best to help you decide what protocol is best for your dog so that they have the least side effects, but with the best chance for remission.
Oncologists have many more options now and most of them focus on quality of life: our pets live much shorter than we do so they need to feel as well as they can during the chemotherapy.
So, I think it would be best to work with your oncologists to see what your options are and particularly if you want to do more than prednisone, I think the lymph node cytology and blood work are a reasonable request. Also, your family veterinarian is still part of your dog's health care team. Don't hesitate to contact them as well as they may be able to talk to your oncologists as well.
Please let me know how it all goes. I know you are already doing the best for your buddy. It is really up to us as veterinarians to answer all your questions.


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