Jasmine's Cancer Story -- The Diagnosis
The Diagnosis
Wednesday, August 4, 2004
Jasmine is our 11 year old Australian Shepherd/Lab mix. Scott has owned her since she was a puppy. We have two other dogs, Levi, a 3 year old brindled German Shepherd mix, and Nixie, an almost 3 yr. old Great Dane who had a TPLO and two other knee surgeries last year. Jasmine has been feeling a bit under the weather for the last week or so, and has started snapping at the two pups when they approach her. I took her to the vet today, thinking maybe her teeth were bothering her again, or maybe she is starting to go blind, or maybe she has doggie Old Timers and is having flashbacks to when she was a pup and was beat up by a burglar. Dr. Thompson, our GP vet, examined her mouth, and started saying phrases like "oh, that's too bad" and "oh, that's unfortunate."
He thinks she has a tumor on her upper jaw, at the front. She does have a large lump there on the outside, and it certainly pains her a lot. He didn't want to waste time taking x-rays (which would've happened tomorrow), and said that I need to get her into the CSU (Colorado State Univ.) vet hospital oncology department ASAP. So, she has an appointment tomorrow morning, but I don't know with whom. I understand they have a great department, and I'm glad it is only an hour away (we live in Cheyenne, WY).
This is my first time dealing with doggie cancer, so what should I expect? What questions do I need to ask? The vet did voice slim hope that it could be an abscess, or something else, but he wasn't very hopeful. So, like the librarian I am, I'd like to go there tomorrow as prepared as possible. I've dealt with dogs with diabetes, arthritis, spondylosis, knee surgeries, and a removal of what our previous vet thought was a mast cell tumor, but thankfully turned out to be a benign puppy fibroma, but not this. I'm not prepared for this.
Jasmine in the backyard of the old house, April 2000.
Thursday, August 5, 2004
We spent the day at the CSU Vet Hospital. The vet in training examined her, then Dr. Ryan examined her, and then they did blood and urine workups, took chest x-rays and a wedge biopsy of her gum, and checked her lymph nodes. Good news—chest x-rays, blood and urine work ups and lymph nodes are well. We'll find out about the tumor tomorrow afternoon when the histopathology comes back. Dr. Ryan wanted to do a CT scan, but we weren't ready to pay that kind of money yet, if it in fact turns out to be something other than a tumor. Because it hasn't spread yet, he wants to do a partial maxillectomy on her on Monday. That's assuming it is some form of malignant growth. They'd do the CT scan then to determine how much of her jaw to remove.
At the new house, enjoying the view
out the window. February 2004.
My husband is torn because he questions the quality of life she'll have with the front part of her upper jaw missing. I question him that if it is malignant and as fast growning as the vets believe, what kind of quality of life she'd have if left it untreated. She's 11, but up until last week, I'd thought she'd out live our Dane. Now I'm not so sure.
We can come up with the money some how. We always do. The estimate for everything was about $3000, of which we paid $500 today. There is a clinical trial going on for oral melanoma, which would pay for part of the bills.
So, we are all in limbo until the "call" comes tomorrow. Then we'll have all weekend to stew over it.
Friday, August 6, 2004
Well, the biopsy came back "gingival hyperplasia" which basically means they don't know what, if any, kind of tumor it is. They want to do a CT scan and surgery on Monday. I'm feeling pressured into doing the surgery, and they haven't done a good job convincing me that it needs to be done. Dr. Ryan is off rotation, so we'll see two new vets on Monday--a surgeon and an oncologist. He believes that they'll have to resect past the canines to her 1st premolar, which seems like it would be about half of her upper jaw. They won't know what type of tumor it is until after the surgery. I want to do what's best for her, and I'm not convinced surgery is it.
I am bitter and upset and angry that they couldn't give me a straight answer. Now I get to stew about this all weekend.
All snuggled into the new chair. What is furniture
without some dog hair on it? February 2004.
Monday, August 9, 2004
Jasmine was at the CSU vet hospital for 8 hours today. At first we were dead set on no CT scan and absolutely no surgery. We did some internet research Sunday night, and without knowing exactly what type of tumor it is, we couldn't come to any sort of conclusion. However, we did discover some articles that explained that even if it was a benign tumor (which they still don't know it is) those are nasty and painful, and a partial maxillectomy is still recommended for their removal.
We saw two new vets today, and they presented other options, like do a CT and then a biopsy, so they could get a good sample. They didn't think dental radiographs would show what they needed to know. My husband and I talked and talked, and we decided to go for the surgery, so she wouldn't have to be anesthetized three times in seven days. She's 11, but she's strong and perky and otherwise healthy, and we feel she'd pull through like a trooper.
Jasmine and Levi playing tug, when Levi was
smaller than she is. Summer 2001.
However, after the CT, Dr. Ehrhart realized how large and extensive the mass was, and she wanted to make absolutely sure what kind of tumor it is before surgery, so we went with the biopsy. If it was mailignant and/or aggressive, then she would resect more jaw, but that would take it back to Jasmine's third premolar, which Dr. Ehrhart wasn't comfortable doing unless she knew it was absolutely necessary. She wanted to opt for a more conservative approach, and take less jaw, but that would mean that if it was malignant, they couldn't go back in and do the surgery again. Dr. Ehrhart is hoping it is a benign epiludes tumor, but it is up in the bone, and larger than a superball, but not as large as a ping pong ball. We had never seen the mass on the roof of her mouth. We just thought it was on the gums. So, we are another $1000 lighter in the pockets, and we are still not sure what we are dealing with. She did get a good sized biopsy, and she mentioned that it has a lot of abnormal-looking cells, so we should get a "good" pathology result. We might know by the end of tomorrow.
It has been an up and down day for us, and we are just beat. They let us take her home, and the poor dog is wandering around the house "drunk" with our other two dogs following her around, sniffing. Her biopsy site was slowing dripping blood onto her tongue, where it dried. She has eaten since she got home, so now she just has to come down off of the anesthesia.
Now I have to keep the 3 year old Dane from trying to play with the old girl.
Wednesday, August 11, 2004
I played phone tag with Dr. Ehrhart most of this morning. The preliminary results from the biopsy taken on Monday are "undifferentiated sarcoma." They are going to do more stains on it to determine what kind. She wants to know exactly what kind of sarcoma she is dealing with before recommending how much of the jaw to remove, or whether we should opt against surgery. Dr. Ehrhart has been wonderful throughout this ordeal. We should know more by the end of this week.
Hangin' out in the fall leaves, October 2003.
Monday, August 16, 2004
The second test on the second biopsy came back a "relatively high grade fibrosarcoma." Jasmine is scheduled for surgery (partial maxillectomy) on Wednesday. We get to see yet another new oncologist. The one we saw last week is off clinical rounds, so we get a third new vet in two weeks. How frustrating. There is also the possibility of doing chemo after this surgery.
I can tell in the week it has been since her CT scan that the tumor is bigger. Her lip sticks out more, and her nose is a little off center. I just hope they can get it all, because we aren't putting her through second surgery. It hasn't spread, yet, but there is a good chance of it doing so, with or without the surgery. She has a lot of fight in her, and I'm trying to keep a positive outlook on things. I'm not ready to let her cross the bridge.
Wednesday, August 18, 2004
We dropped Jasmine off for her partial maxillectomy this morning. Despite the wind and construction, it was a beautiful drive, with a rainbow over the Rockies. Rainbows are always welcome here, especially since we are in the fifth year of a drought.
We met the new oncologist today, Dr. Bill Dernell, who had a lovely tropical fish tie on. He mentioned that he might be able to salvage part of the right side of her jaw, which would help the reconstruction of her nose. The student doctor is Stephanie Williams, who is Jasmine's beautician. Last week, when we thought we were going to do the surgery, Steph started shaving Jasmine, so she's had half of her face and spots on all four legs shaved before she got the page that the surgery had been postponed. Dr. Dernell said that he can usually get all of the tumor 90% of the time. We didn't discuss chemo, but that might not be mentioned until after the pathology comes back on the tumor. Jasmine is scheduled for surgery this afternoon, and we can pick her up tomorrow. Nixie, our Great Dane, is frantically running around the house looking for Jasmine and has whipped me twice with that tail (ouch!).
Thanks go out to everyone on the Cancine Cancer and Orthodogs lists for all of your positive thoughts and energy. I'm feeling confident that we made the right choice, and that she will be fine.
Hammin' it up for the camera. October 2003.
Wednesday, August 18, 2004
Jasmine is out of surgery and has woken up. Dr. Dernell was able to save her right canine and last incisor, but I'm not sure how far back on the left side he had to take (3rd premolar?). He said that she looks well for the type of procedure that was done. He kept telling me that she looks like a truck hit her, but I think that is to warn us before we actually see her. Her nose is crooked, but then, the tumor was pushing it to the right. There is an indentation on the left side where the jaw was removed, but that is to be expected. Pathology will come back in a few days (Monday?) to see if he indeed got it all. There has been some bleeding, but it has stopped. They don't want us to visit her tonight because she'd get all wiggly and bleed again. We can pick her up tomorrow. Scott will stay home with her on Friday to make sure she's ok and the other two dogs leave her alone. Oh, and chemo wasn't mentioned, and I forgot to ask.
Jasmine flaked out on the dog bed in the living room.
August 19, 2004.
Thursday, August 19, 2004
We went and picked up Jasmine this afternoon. Dr. Dernell had told me about the swelling, how she looks like she has a Roman nose (well, she does now), and how she looks like she was hit by a truck. I figured that since the surgery was to her face, that she would look like she had a head on collision with a truck, but that isn't the case. The bridge of her nose is swollen, and her nostrils are now on the left side of her face. Her lower left canine sticks out now, so she kinda looks like a bulldog. She looks almost normal from her right profile, and she doesn't look nearly as bad as I had imagined from her left side. There is no apparent bruising on the nose, and they didn't shave her face. She breathes funny, but they said that would improve as the swelling goes down. They sent her home with a fentanyl patch and morphine. We go back next week. I forgot to ask about when the pathology would come back, but I'll ask that when I make her follow up appointment tomorrow. She has eaten, drank, and did #1 and #2, so all body functions are working. She was even able to eat her chewable Rimadyl tablet. She perked up when she got in the van to go home, and sat in the back seat looking out the window the whole trip. I have a good feeling about this, and I hope the pathology bears that out.
Levi layed there and looked over her.
August 19, 2004.
Nixie kept trying to cheer up Jasmine,
which got her yelled at. Here she lays keeping
watch. August 19, 2004.
I woke her up taking this picture. This will be the
absolute worst she'll ever look like. August 19, 2004.
Friday, August 20, 2004
The swelling has gone down some, but she looks like a bull terrier from the right profile, and a bull dog from the left. Looking at her straight on she reminds me of Jimmy Durante, or some cartoon monster that I can't remember. That may change as the swelling decreases. Her lip has gone over her left lower canine, but it usually sticks up. That may also change with time. You can see the big chunk of jaw they removed by where her nose lays.
Getting her to take her morphine and Rimadyl tablets was hard this morning, but she eventually did it. Her breathing is sometimes labored, with a bit of a gurgle or a rattle to it, but she eventually relaxes and breathes normally. Scott is home with her to keep her safe from the other two, very worried, dogs, and to make sure she's ok.
She ate some food at lunch, and took her morphine pill. The swelling has reduced since this morning, and so has the gurgling. We go back on Wednesday for a follow-up, and Dr. Dernell hopes that the pathology will be back by then. They have to decalcify the tumor, so it takes a bit longer.
Jasmine enjoying the sun, August 22, 2004.
Monday, August 23, 2004
We took Jasmine off of morphine today. She is definitely perkier than she had been. She even ate a whole, cooked chicken breast (cut up in small pieces). The clots in her nasal cavity must be breaking up, because she has been coughing and sneezing up spots of bloody mucus all afternoon. We ran out of Woolite Oxy Carpet cleaner, and had to bug the in-laws to come over with their half bottle. They got to see their little piglet dog, which made the trip worthwhile. Her allergies are probably bothering her, too (I know mine are!).
Wednesday, August 25, 2004
We took Jassy to the CSU vet hospital today. An hour down there, wait twenty minutes, they examined her for five minutes, and then an hour back. Her sutures are holding and her mouth is healing fine. She still snorts and gurgles and sneezes, but they say that is normal and should go away soon. She's on soft food for another week. The pathology results weren't back yet. Dr. Dernell said that the premaxilla is composed of very dense bone, and that it takes time to decalcify the tumor they removed last week.
Dr. Dernell did call us this evening with preliminary results on the pathology. They got clean margins (yeah!) and it appears to be "osteosarcoma like." He tried to explain to me what "like" meant in tumor terms. I asked how they thought it was fibrosarcoma with the second biopsy, but now they think it is osteosarcoma. He explained that with the biopsy, they probably got and/or saw lots of fibers, hence the diagnosis of fibrosarcoma. Now, they are seeing a bone matrix created by the tumor, so they are calling it osteosarcoma. Now I need to reread all of those articles I interlibrary loaned to find out survival rates and recurrence rates with osteosarcoma. Ugh.
The short version is that they still don't know exactly what we're dealing with, so they can't recommend further treatment. What's next? Radiation? Chemo? Some form of alternative medicine? Nothing? If nothing, then she goes back for follow-ups every three months, and has chest x-rays taken every six months.
Monday, August 30, 2004
I've talked with Jasmine's onco-vet (is that a word?) today to see if he had any clearer diagnosis as to what her tumor was. The senior pathologist still says it is high grade, and is leaning towards osteosarcoma. It seems to be some sort of fibrosarcoma/osteosarcoma mix. The second biopsy was more fibrous (fibrosarcoma), but the actual tumor showed bone development (osteosarcoma). They want to treat it like a high grade osteosarcoma.
They also want to do chemo on her, for five doses, every two weeks. It'll be adriamycin on an outpatient basis. The onco-vet mentioned that there hasn't been a whole lot of studies done on osteosarcoma of the jaw, so he doesn't know quite what we're getting into (nothing like navigating through uncharted waters). In doing literature searches, I'm not finding much, so I just don't know what to do. Her first chemo appointment is Thursday morning, if we go ahead with it. I think I need more questions answered before we do.
Looking dazed and confused, drugged on
Benadryl, wearing her new e-collar.
September 2, 2004.
The only apparent side effects from adriamycin would be some mild GI problems for a day or two after each dose, which they would give her stuff for, if that was the case. I looked up the drug sheet for it (generic doxorubicin) and if she had heart or liver problems they wouldn't give it to her. If she had heart or liver problems, we wouldn't have gone through with the surgery in the first place.
She's doing fine and back to eating her regular dry kibble. Her only problem is her allergies and her whiskers growing back are driving her crazy. She's on Benadryl for that, because I don't want to try to get an e-collar over her head right now.
Tuesday, August 31, 2004
I've talked with Dr. Dernell about survival rates, if we do or don't do chemo on her. The chance of local recurrence is low (about 10%), because they got clean margins. However, the pathologists don't look at the entire tumor, just a representative sample, so there may be tumor "fingers" that extend past the margins that they don't catch. He said that the reason for chemo on top of the partial maxillectomy is that OS without chemo has a 70-80% metastasis rate. He then rattled off numbers for long bone OS--90% metastasis rate with amputation and no chemo (avg. 3 months to lungs). With surgery and chemo, long bone OS may not metastasize for a year or more. Any survival over two years is considered successful. There isn't much data for non-long bone OS.
I asked him about her trying to tear out the inside of her mouth. He said that her nerves at the surgery site are firing back up (I think the word Dr. Dernell used was "re-enervate"). He said it is worse in some dogs. It is driving her crazy. She keeps scratching at her mouth, so she is wearing Levi's old e-collar and given a Benadryl to slow her down while we are at work. Those spasms are happening less frequently now, so maybe they'll be over soon.
We discussed it and felt that what was the point of doing the surgery, if we weren't going to go all the way with her treatment, so we kept her chemo appointment. Of course, I may feel differently if she has a bad reaction to the adrimycin. Also, all of the tests, surgery, and chemo will be less money than we spent on Nixie last year for her 3 knee surgeries.
She had a good 11th birthday--got homemade 3 Dog Bakery brownies (made with carob, of course!). She ate one in two bites!
