diagnosis

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Berry's Diagnosis & Treatment

The Diagnosis

On February 17, 2000, I took Berry to the Veterinary Hospital of the University of Pennsylvania (VHUP) because he seemed to have a cold. Symptoms included sneezing, red eyes, and a runny nose. He had also experienced repeated lameness and a slight weight loss. To my surprise and distress, Berry was tentatively diagnosed with lymphosarcoma (lymphoma) based on enlarged, hard lymph nodes in his neck and elsewhere, an enlarged spleen, and his breed and age. We would receive the results of blood work and lymph node aspirates that night, but were told that the top three most likely diagnoses were: "lymphoma, lymphoma, and lymphoma". Since Berry's condition had been reviewed by VHUP’s Oncology Service, run in conjunction with the University of Pennsylvania’s School of Veterinary Medicine, with a special residency in small animal oncology, I was prepared for the inevitable news that evening.

The next day, additional tests (a complete blood count, chest x-ray, abdominal ultrasound, and a bone marrow aspiration) concluded that cancer cells were present in Berry’s external and internal lymph nodes, and in his blood, bone marrow, and spleen. The diagnosis was refined to "Stage V Mature Cell Lymphosarcoma". This meant that, although Berry had few symptoms, the cancer was very advanced. We were shocked: Berry had been evaluated by a veterinarian when he entered DVGRR’s adoption program in October 1999 and had had a complete physical exam, including a complete blood count, at VHUP, in November 1999.

VHUP gave us some basic information about cancer in dogs. Berry’s life could be extended, probably 4-6 months VHUP predicted, with chemotherapy; without treatment, he would die soon. We agreed to begin chemotherapy treatment that day – February 18 – using a treatment plan developed by VHUP’s Oncology Service – and made an appointment for Berry to be formally admitted to the Oncology Service. Because the Service treats a large number of pets with cancer and only admits a limited number of new cases each week, the first available consultation was March 15, which seemed like an eternity.

Round One

On February 18, 2000, Berry’s treatment began with an initial injection of L’asparaginase ("Elspar") and a prescription for prednisone. Berry had no negative reaction to the Elspar but the prednisone made him drink a lot; after a couple of accidents in the house, we figured out he needed to pee every 2-3 hours. We increased Berry’s food. On February 25, Berry received an intravenous drip of .8 mg of vincristine. The vincristine had no immediate side effects, but four days later, Berry began to vomit repeatedly and paced constantly, as if unable to find a comfortable spot. We withheld food and water overnight, but he vomited repeatedly again after food was reintroduced. He could not keep food or water down and eventually became dehydrated, trembling from an electrolyte imbalance.

On March 1, Berry was admitted to the emergency service at VHUP; a visit to VHUP that night revealed an exhausted, depressed dog, an IV drip of electrolytes in his shaved paw. Berry’s sides, already shaved for the ultrasound in February, were further shaved to check for a possible intestinal obstruction. His ribs were prominent. Both front feet were shaved and bandaged from numerous tests and IVs. Berry was released from VHUP the evening of March 2 with instructions to reintroduce food slowly, but the following day, after hand feeding, began vomiting again. Then, he refused both food and water. Berry was to have received a 75 mg dose of Cytoxan (cyclophosphamide) each day for four days beginning on March 2. But we were terrified to introduce another drug, especially one that sounded very toxic – and what good would be done if the pills were vomited up? So we waited anxiously.

Because Berry had not yet been admitted to the Oncology Service, we received contradictory information about whether or not the vomiting was a vincristine side effect and how to treat it. Worried about further dehydration, we soaked Berry’s paws in Gatorade so that, in licking them, he would take in small amounts of liquids. On Saturday, March 4, we returned Berry to VHUP for more IV hydration. We talked about discontinuing all treatment; we had had the best of intentions, but maybe we were being unrealistic. In the space of two weeks, Berry had been diagnosed with a terminal illness, was despondent, and looked like a bag of bones. I asked Greg, our closest dog friend, to be Berry’s advocate, charged with speaking for Berry’s best interests. We agreed that Berry would not die at the hospital; the neighborhood vet would come to our house if we decided to put Berry down. But for the moment, we made Berry a special bed in the kitchen and waited for a change for the better—or the worse.

A Turning Point

On Sunday, March 5, Berry kept down his first food in 4 days. He was too weak to walk around the block, but he acted like the old Berry, rolling in the leaves in Greg’s yard, happy to be outdoors, in the sun. We knew we had to keep going and we realized we had to take more active control of Berry’s care. That week, I had a lengthy conversation with Dr. Lisa Barber, the principal oncologist who would manage Berry’s case in the Oncology Service. Here was the expertise – and the compassion – that we and Berry needed. Here was someone who could speak with authority about the subtleties of treatment, alternate drugs, and side effects. Reviewing recent events with Dr. Barber, it became clear that Berry’s crisis had likely been a vincristine side effect – one that could be managed. We agreed to continue the prednisone and start Berry – a week late -- on a reduced dose of Cytoxan.

On March 15, Berry was formally admitted to the Oncology Service. During a lengthy consultation, we learned an overwhelming amount about lymphoma, chemotherapy and management of side effects. Follow-up blood work was done and we were promised a call with the results the next day. Dr. Barber recommended that vincristine be tried again, at a reduced, but therapeutic dosage. Vinblastine could be substituted if reducing the vincristine dosage did not reduce the side effects. Dr. Barber prescribed metoclopramide, an anti-nausea medicine, to counteract the vincristine side effects. We kept careful notes and administered the anti-nausea medicine at the first sign of Berry’s discomfort. Dr. Barber called to say the lymphoma was reacting to the drug therapy: the percentage of cancer cells in the blood was down dramatically -- success!

Treatment Continues

Berry’s course of treatment -- his weekly sequential protocol of elspar, vincristine, Cytoxan, vincristine, each coupled with a daily dose of prednisone -- became a routine. Every week, the doctors checked the external lymph nodes and spleen. The changes were gradual but positive: each week, the lymph nodes, spleen, or both, seemed a little smaller. The dosage of prednisone was cut and the frequent urination problem vanished. The Cytoxan was increased to a full dosage without incident. Berry’s blood counts continued to look good. We had read that dogs in chemotherapy may lose interest in food, but Berry gained weight until he was a round ball of fur. We began to think Berry might spend the summer with us, but we took him to the beach in May just in case.

At the completion of four cycles of drug therapy, on June 8, Berry was "restaged". This included a complete blood count, chemistry screen, urinalysis and bone marrow aspiration. Based on these test results, we decided to forego an abdominal ultrasound -- we did not want Berry shaved again unless the other test results proved ambiguous. Berry’s discharge classified his status as "Lymphosarcoma -- complete remission", meaning that there was no detectable level of cancer cells. This did not mean Berry was "cured" -- just that the cancer had been beaten back. Berry’s treatments were spread to every other week. Berry seemed to gain energy as the prednisone dosage was reduced and again when the chemotherapy treatments were spread out.

Current Status

12/31/03: On October 13, 2003, Berry The Dog left us to sleep The Big Sleep. In September, Berry's health and quality of life had declined rapidly. We and VHUP initially believe his decreased activity and intermittent diarrhea over the summer were side effects of his new chemotherapy. But a continuing depletion of his platelets and red blood cells and the identification of several other tumors suggested more complex causes, perhaps an autoimmune reaction or other, internal cancers. After final visits to BerryBrook, the Dog Park, and his other favorite haunts, we let him go.

Early in Berry's treatment, we had resolved that he would die at home. In early October, we made plans, calling the neighborhood vet and the pet crematorium. But at the very last, we realized that Berry belonged at VHUP, and we took him there to be with the people who had cared for him so well, for so long. He died peacefully in the Oncology Service -- his second home -- with a fluffy toy in his mouth, as I cradled his head in my arms. We will never be able to thank Dr. Baez and Roxanne Bachman enough for their kindness to Berry and us in his final experience.

When we left VHUP, we retraced our route through the neighborhood with Berry The Spirit Dog now in the car, pointing out things he needed to know -- that he no longer needs a key to get into the Dog Park, or us to take him there, and that he can pee on the ivy at the corner as much as he wants.

Berry was 7 1/2 when he died. He lived longer with lymphoma -- nearly 4 years -- than he did without it; ironically, his lymphoma was in remission again until a week before he died. To the end, he was the best dog, with the biggest paws and the silkiest coat in the world. We know he will always be there -- in his "Barkatorium" in the vestibule, in his "Office of Homeland Security" on the landing, and in his corner of the bed, enjoying a late morning snooze. Berry lives on through the Pets with Cancer Lifeline and Every Day is A Good Day, our handbook to help other owners.

6/27/03: Yesterday, Berry visited VHUP and today we received word that he is coming out of remission again based on lymph node aspirates. He got 18 great months on the Leukeran, but now it is on to a new drug, Lomustine. We'll keep our fingers crossed that it is effective.

2/17/03: Three years since Berry's diagnosis. VHUP had to reschedule the celebration of their new oncology ward because of the big snowstorm, but we'll be there this Sunday.

11/06/02: Still in remission, Berry laid claim to "BerryBrook", his and Otto's new romping ground in Vermont...woods, a meadow, a brook! There was 6 inches of snow on the ground, so Berry got to practice his "snow angels".

5/27/02: Berry had a great birthday on April 22, and a fine check-up on May 10, including a "perfect" bone marrow cytology. He couldn't wait to see Roxanne and meet the new students at VHUP. We are looking forward to Dog Camp at Camp Gone to the Dogs in early June, where Berry can practice his superior water entry.

4/1/02: On December 16, 2001, we noticed blood in Berry's urine and immediately took him to VHUP. He was ultimately diagnosed with a benign sterile cystitis (possibly a delayed reaction to the cytoxan he had received in prior chemotherapy). But the veterinarians who examined Berry also grew concerned that he was coming out of remission, and in early January 2002, made the diagnosis that Berry was out of remission. Leukeran and prednisone, both given in pills, were prescribed. Berry has been doing well on this therapy, with no side effects, and we are looking forward to Berry's 6th birthday on April 22.

Sadly, Berry's adoptive dog-mom, Amanda was euthanized on March 21, 2002 after mast cell tumors recurred throughout her body. She was believed to be over 12, and she spent her last three, wonderful years with Richard, Lois and Cheryl.

11/2/01: On November 2, 2001, Berry had his third re-examination following termination of chemo. Again, great results: Berry's VHUP discharge read as follows: "Happily, the results of Berry's blood count and chemistry screen are perfectly normal!! This in addition to the beautiful physical examination findings indicate that he remains in complete clinical remission." What more could we hope for?

First, that there weren't so many goldens with cancer. In recent weeks, Amanda Jones (see Berry's Pix) has had a cancerous tumor removed from her leg, and Stanley, a 10 year old pal of Cody's, without warning was discovered to be filled with tumors and in the last stages of life. We remember when we learned that Berry had lymphoma, and are thinking of Lois, Richard and Cheryl, and of Stanley's owner, Sara.

Second, that we are able to keep in touch with Berry's oncologist, Dr. Lisa Barber, who is leaving VHUP. We can't thank her enough for everything she has done. While we know that the other professionals in the Oncology Service will do a super job, Dr. Barber brought Berry (and us) through the critical early days of his treatment.

Finally, that there were fewer dogs without good homes. On November 4, Berry celebrated two years with us -- in his new life with the good food, soft beds, and attention he missed out on in earlier times. A day we thought we'd never see.

8/17/01: On August 17, 2001 Berry was restaged at VHUP at the end of 18 months of chemotherapy. Berry came through with flying colors. Berry is one of the lucky dogs who makes it this far -- to the point where the doctors consider discontinuing chemotherapy. We were counseled that our choice was to either discontinue chemo now, or to continue for another 6 months. Because relatively few dogs are so lucky, there is little hard data on which to base a decision. Of the dogs that make it to this stage, 60-80% will not have a recurrence, but 20-40% will.

In consultation with Berry's oncologist, we decided to stop chemo. Continuing might have kept him in remission for another 6 months, but our oncologist also indicated that it can be harder to achieve a second remission if the dog is in chemo at the time the lymphoma returns. We decided to give Berry a break now.

Other positive information that we heard was that VHUP has had better success in achieving a second remission in dogs with Berry's type of indolent small to intermediate cell lymphoma than with other types. So that gives us hope that, should Berry come out of remission, there will still be some treatment options. For now, Berry will be visiting the Oncology Service at least once a month for a checkup.

3/2/01: On March 2, 2001 Berry was restaged at VHUP as he came to the end of an 8-month treatment cycle. Berry's blood work was in normal limits and his chest x-rays showed no cancer in the lungs and lymph nodes; in addition, his chemistry screen characterized by the VHUP doctors as "beautiful" and his bone marrow was "even more beautiful -- perfectly normal." Yay Berry!!!!! Based upon these positive results, Berry's chemotherapy treatment cycle is being spread out so that he now will receive treatments every 3 weeks (in contrast to every 2 weeks as had been the previous protocol).

2/17/01: We are happy to report that on February 17, 2001 Berry The Dog experienced a happy day going for two long walks, spending some excellent "quality time" snuggling with Carol on the bed, and partaking in a some great "food opportunities" that included "lick'ems" and "catch'ems" from a nice steak dinner cooked by DC. So what's so special about all this? Sounds like a not-so-untypical day in the life of Berry The Dog. But this was special, because it all took place on the anniversary of the day that Berry was diagnosed with lymphosarcoma a year before. And it was special simply because it was so unspecial. Just another happy day in the life of a wonderful pooch. We take one day at a time with Berry and try to make sure that every day is a happy one for the namesake and spiritual master of dogdoggiedog.com.....

01/17/01. Berry has been in chemotherapy for 11 months. If he continues to be in remission in late February 2001, he will be restaged. Treatments then probably would be spread to every three weeks; at 18 months, treatments are discontinued on dogs still in remission. . .but that’s the unforeseeable future. We take each day with Berry The Dog as it comes and do our best to fill it with the love and attention he did not get in his prior life. We are thankful for the time Berry has had with us and credit Berry’s successful treatment to his spunky personality, our diligence, and the care he has received at VHUP.