Phoebe, The Baroness Von Peebleschnopps

Wednesday, October 9, 2013

The Latest on Phoebe

There is a lot to update here as it's been a long week for us. Let be backtrack to 5 days ago, on Friday, October 4th. We brought Phoebe into the vet that day because she had been vomitting for 36 hours.  She had vomited her breakfast up on Thursday and our dog walker found it when she came to walk her at lunch. That night, Michael fed her dinner and about an hour and a half later she vomited it all up, again.  When she vomited her breakfast up on Friday morning, we brought her into the vet emergently. We were concerned that she might be experiencing some sort of intestinal obstruction/blockage.  That was the impetus for bringing her to the vet.

We had noticed for a few weeks prior to this that Phoebe was having more urination accidents in the house. Specifically, in the evenings after her dinner, she no longer could make it for 4 hours after dinner until the bedtime walk. Every night, around 8 pm, she has been jumping up and needing to go pee suddenly and urgently. If we don't notice it in time, she pees the floor.  We mentioned this to our vet because we had been going through a three week period wherein we were taking her off the Trilostane (the medication for her Cushing's disease).  Our concern about the frequent urination was that it might have been a sign of her Cushing's disease coming back which would mean that we'd have to restart the medication.

Her doctor a full panel of bloodwork, an ACTH stim test (that measures her Cushing's disease), a urinalysis as well as an abdominal ultrasound on Phoebe. The good news was that her intestines looked fine and there was no obstruction.  The bad news was that there was a 7 mm mass in her bladder.  More specifically, it is in the trigone of the bladder.  The trigone is a region of the bladder where tumors are particularly difficult to treat, rarely operable, and most often found in dogs.  We waited a day for the blood and urine results. If they were normal, we would think that this was a all coming from the tumor. If they were abnormal, it might have indicated an occult Urinary Tract Infection (UTI).  The vet was clear that many dogs with a subacute/occult UTI experience vomiting as a response to it.  They administered an injection of Cerenia (anti-nausea medication) as well as an antibiotic to her to start treating the UTI empirically on Friday.

The next day, we got the results: totally normal blood work and urinalysis. Specifically, her ACTH stom test levels were normal which was great considering that she had been off the Trilostane for a few weeks.  So it wasn't Cushing's disease.  Her urinalysis showed no blood, no white blood cells, no castes, and no changes in the specific gravity. In other words, there was likely no infection here.  This got us very concerned because the only positive finding, at this point, was the mass in her bladder.

Statistically speaking, when an older dog (older than 10 years of age) has a mass in the trigone of the bladder, it is most likely The transitional cell carcinoma (TCC) until proven otherwise.  TC see is the most common of all bladder tumors in dogs.  Sadly, it's extremely aggressive and metastatic.  Knowing this and that Phoebe, at 15 and half years old and female had a mass in the trigone of her bladder, we rushed that very afternoon to meet with a surgeon about doing a possible biopsy to start treatment for this. TCC is very aggressive and must be treated very early and quickly have any positive results.

We met with Dr. Greenberg at Blue Pearl Veterinary Partners. He was very clear with us: the only way to know exactly what this is would be to take a biopsy of it.  He was also very clear to say that, based on the location in the trigone of the bladder and considering the small size of a Chihuahua's bladder, it would be nearly impossible to take out the entire mass and a 1 cm margin is the standard for removing a tumor.  He mentioned that we could do this via cytoscopy.  Still, this would require anesthesia and the trauma of surgery: making an incision in her abdomen and going into the bladder to obtain a piece of this mass with no potential to eradicate or fully remove this mass. He also mentioned that there is a test for TCC that checks for antibodies made against these tumor cells that are shed into the bladder. The test, called V-BTA (bladder tumor antigen) is about 90% sensitive but only 78% specific.  Though this test is associated with many false positives, there are few false-negatives. What that means in English is this; If your dog has a positive V –BTA test, she may or may not have TCC.  But, if your dog has a negative V–BTA, then it's very likely that she does not have TCC.

We have been waiting for four days for the results of phoebes V-BTA test. In the meanwhile, we had made an appointment to take her to visit with an oncologist this afternoon. In fact, it's the same oncologist who took care of Chandler when he was fighting malignant melanoma, Dr Tim Rocha.  Just hours before going to the appointment, we got the news that Phoebe's test was negative. In other words, her bladder tumor is most likely NOT TCC.

We just got home from our later afternoon visit with Dr. Rocha.  There were a lot of questions. Do we treat this empirically as TCC or not?  Do we reconsider doing something invasive to find out what the tumor is made of?  Dr. Rocha pointed out that many benign tumors continue to grow in this region, the trigone of the bladder, and still effect the same changes and problems that the progression of TCC does, albeit without metastatic disease.  In other words, even though this now likely to be a "benign" tumor, it's still most likely going to continue to grow, eventually overtaking her bladder, one or more of the ureters and causing her kidneys to fail.

Many of the medications used to treat bladder cancer in dogs are NSAIDS, nonsteroidal anti-inflammatory drugs.  Specifically, older NSAIDS like Piroxicam have been shown to slow tumor progression in both TCC as well as many other benign bladder tumors. It would be a no-brainer that we should start her on it but Phoebe has bad a history with NSAIDs.  After many years of being on many different medications, she is very sensitive to this class of drugs. As it stands, her renal function (as measured by a BUN/creatinine) has been chronically elevated for many years. More importantly, when she has taken any NSAID (even for just a few days) it has thrown her renal function way off and we usually end up taking her off the medication after a week or so.  In a 15 1/2 year-old senior dog, everybody is reluctant to start her on this.

Many of the chemotherapy drugs that are platinum based are extremely harsh and toxic.  Dr. Rocha strongly advised against using this in Phoebe, even if she were to have a documented TCC pathology.  He feels that this is just too strong a class of drugs for her at her age and size.  We agree.

There is a relatively newer chemotherapy drug called Palladia (toceranib phosphate).  Palladia is the first FDA approved oral chemotherapeutic agent for cancer in dogs.  Unfortunately, the only studies on Palladia have been in limited studies of mast cell tumors of the skin in dogs.  That has not stopped veterinarians from using this to treat a wide array of different types of cancers, including TCC.  The nice thing about an oral medication like this is that side effects, if encountered, tend to be quickly stopped and reversed.  This is not the case with infused platinum based IV chemotherapy.  Still, Palladia is a very expensive and unproven medication with respect to TCC. More importantly, there is no evidence to suggest that it is useful in treating benign bladder tumors which we now know is more likely to be what is growing in Phoebe's bladder.

Michael and I have spoken about this at some length and we are in complete agreement.  Phoebe is approaching the end of her natural lifespan.  Of course, we want her to be with us as long as is possible. We do not, however, wish to achieve longevity at the expense of her comfort and quality of life.  It is for this reason that we are extremely reluctant to even consider and invasive surgical procedure to biopsy this mass.  In reality, whether this is TCC or some other benign tumor, it will likely continue to grow.  How fast it will grow, nobody can know.  Having done the antigen test, we feel reasonably confident with the 90% chance that this is not TCC.  That means that, since it is not TCC, there will most likely not be metastasis to other parts of her body.  So really, what were looking at, is treating and containing the growth of a benign tumor non-surgically.

We are in agreement with Dr. Rocha as to our plan. We are going to wait four weeks, add no medication at this time, and then we will recheck her ultrasound and x-ray scans. If the tumor has grown or if there are any signs of metastasis, then we will weigh our options as to the risk of using an NSAID versus starting something like Palladia.

It might be wishful thinking but, knowing who Phoebe is: her history of surviving against the odds and outliving every statistical probability for each diagnosis she's ever been given, it would not surprise us in the least to see no tumor growth or even tumor regression in four weeks. For right now, we are going to enjoy every day with her and we will cross those bridges if and when we come to them.

Friday, May 10, 2013

La Quinceañera; Miss Phoebe turns 15 years old

I am feeling a bit disoriented today.  It's hard to believe that it's May 10, 2013 and Phoebe is sitting on my lap as I drink my morning coffee and read the news.  You see, today is a day that I was told would most assuredly never come.  My little girl, Phoebe, turns 15 years old. It seems that since the day I met her there has always been a challenge to her health and survival and, yet, she always prevails.

I met her on May 7th, 1999 when I went to the Manhattan CACC (New York City's kill shelter).  I was looking for a companion for my dog Blackie.  The only dogs available that day were too big for him and for my small studio apartment, so I was leaving with the intent on coming back another day.  That's when the cops rushed in with a small tan and white chihuahua who appeared to be dead, wrapped in a blanket.  I waited around and watched them from a distance working on her.  She stared at me and our eyes met and I knew I needed to rescue her.  I enquired as to her status and they told me it was unlikey that she would survive her ordeal; Her owners moved out of their apartment, chained her to a radiator and left her without food or water for days.  When the landlord went in to inspect the apartment to make sure his tenants moved out, he found what he thought was a dead dog- Miss Phoebe.  He called the cops and they found her alive and rushed her to the CACC. I told them I was still interested and if she survived, to please call me.  I got the call from the CACC when I was up in Albany visiting my grandmother and mother for Mother's Day weekend that she survived and that I had 24 hours to come and get her.  So I went back to New York, headed to the CACC and rescued her.

Phoebe's next challenge that she survived was a near-death bout with IMHA when she was just 2 years old. I was told that 50% of the dogs who have this died before 3 years out and greater than 85% were gone by 5 years out.  So when we made it past her 7th birthday, my attitude was that we were living on borrowed time.

When Phoebe was diagnosed with Cushing's disease in February 2007, Michael and I were devastated.  We knew this was a possibility, as she had been on steroids for over a year (which increases the risk of Cushing's later in life) but it never occurred to us that Phoebe might live into her old age.  We were "over-prepared" for the idea that she would most likely not live a normal lifespan for a small dog.  In new territory, dealing with later-in-life health issues, we became immediately determined to get her whatever the latest, cutting-edge treatments were to restore her health.  We put her on a new (at the time) drug, Trilostane and hoped it would work.  Thrilled when it did, our vet was always cautious to tell us that the mean survival time on this drug was just 2 years.  That was over 6 years ago.  Again, she survived.

It has not been easy in the past year and a half.  Phoebe is definitely showing signs of her age.  Her bout with Idiopathic Vestibular Dysfunction last year wore her down.  Like her brothers Blackie and Chandler when they became very old, Phoebe also has difficulty hearing us.  The dog who used bark when she heard cars pulling up to the driveway from up in her bedroom can now easily sleep through my arrival at home and all the jumping and noisy fanfare her two younger brothers create for that nightly event.  Phoebe also tore her ACL last year and we opted against surgical intervention (for a number of reasons).  She's adapted well to her limp though she is sometimes frustrated by having only one good, strong, reliable rear leg.  Still, she runs around and chases her brothers, explores the yard and she often makes a mad dash away to the far end of the Zen Garden when I tell her it's time to come in from the walk.  She's still got spunk.

For me, Phoebe personifies survival against all odds in a way that no other person in my life has.  She has taught me to see the "odds" and the "statistics" as mere numbers that suggest patterns but that say nothing about the exceptional individuals who defy them.  She has inspired me to be exceptional, as she is.  Most of all, Phoebe's tenacious, fierce, loyal and intensely loving personality has rubbed off on me and I can now see that I have become much like her in the third of my life- these past 14 years- that we have been together.  So on her "Quinceañera", I say to my sweet survivor girl, Happy Anniversary my love.  You have changed my life for the better and I will always be grateful to you for that.  As is the case for adopted/rescued companion animals, your anniversary is also your "birthday".  So, happy 15th birthday my darling.  I look forward to enjoying today with you and every day to come for as many years as we have left together.

All my love,