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Chapter 1

Hearing a Lymphoma Diagnosis

A Surprise Diagnosis

Luck mostly ran in Berry’s favor. I had almost cancelled Berry’s appointment at the Veterinary Hospital of the University of Pennsylvania (VHUP) on February 17, 2000. Was it silly to go one of the busiest veterinary teaching hospitals in the country with a dog with a few minor symptoms – red eyes, sneezing and a runny nose -- that probably added up to a cold? Probably, but something just didn’t seem right.

The fourth year vet student who did the initial physical exam kept checking and rechecking Berry, and then, with a vague explanation, left the examination room. I waited, alternately worried and bored, while Berry investigated the wastebaskets and eventually flopped on the floor, characteristically resting his head on his paw. The student returned with a woman who introduced herself as Dr. Sally Bissett. She silently checked and rechecked the same places – Berry’s neck and chest, his abdomen, and his legs. Then, she turned to me and said "We think your dog has lymphoma," and I felt the air sucked out of my lungs.

How could this be? He was young and healthy, or so we thought.

A Lucky Forever Home

Going to VHUP that day was Berry’s third lucky break. The first was that the Delaware Valley Golden Retriever Rescue (DVGRR) found Berry; the second was that the Rescue decided he would come home to us, six blocks from VHUP.

Born in April 1996, Berry had been rescued by DVGRR in October 1999 from an SPCA shelter where he had been relinquished by his prior owner – some of the paperwork we received said "cruelty investigation". Tied outdoors until rescue, Berry’s intake papers on October 21 indicated he was dirty, flea-ridden, and underweight. His coat was brittle from poor nutrition. He was described as a "very nice, calm dog".

DVGRR’s veterinarians did a basic physical exam. His ears were "very odiferous", and he was intact (not neutered), with one undescended testicle, and some wear on his canines, but otherwise, his exam was unremarkable. His heartworm test was negative. His eyes, heart and lungs, abdomen, and hips were all normal. His lymph nodes were normal on physical examination. If Berry had been eight or older, DVGRR’s veterinarian also would have performed a complete blood count (CBC), a urinalysis, and a chemistry profile. Among other things, the results of these tests might have suggested the presence of lymphoma. Berry was neutered on October 22, 1999, and sent to a DVGRR foster home with Lois and Richard Koskey and his Dog-Mom, Amanda Jones.

My husband DC and I had been on DVGRR’s waiting list for six months. My friend Greg was first in a chain of adopters, with Cody, a huge red dog described as "an overstuffed puppy" in the DVGRR newsletter. Smitten with Cody, I had requested a big, red Golden too, but we agreed to go and see "Barry" on Halloween afternoon, 1999. For me, he was too small and too light, but for DC, who had never had a pet, much less a dog, it was love at first sight. On November 4, 1999, Berry arrived in Philadelphia; at age 3 ˝, he was home at last. A thin white envelope of information from Lois advised that Berry was a "cuddler" who liked to have lots of fresh water, to be brushed, to shred stuffed toys, to counter-surf if you turned your back, and to scoot out if you opened the door. He would definitely need obedience training, she said.

We were determined to give Berry the easy life he had never had – the run of the house, an abundance of good food, lots of good walks and romps, a soft bed, and a glossy coat burnished by frequent brushing and petting. We quickly found Berry to be a wonderful, ever-so-quirky dog, loving of attention, accepting of human snuggling, oft-times impervious to reprimand, and focused on food (and possible "food opportunities") in a way that made you certain that he had been hungry in his prior life (but then again, he was a Golden). Berry ate like a horse and quickly added the missing pounds and then some.

And he would receive the best veterinary care: even though he had been evaluated by DVGRR’s vet, I took Berry to VHUP for a further checkup on November 19, three weeks after he came home. One thing that concerned me was that his eyes seemed bloodshot. He received a physical exam, a complete blood count (CBC), and a chemistry screen and urinalysis. The results were unremarkable except that Berry’s lungs sounded "dull", a condition for which the doctor did not recommend any specific follow-up.

We started Berry in obedience class in January 2000 after the holidays. We cut back on his food since he had put on weight and would be getting lots of training treats. By mid-January he seemed to be catching on: he tugged less on his lead, and seemed more docile. He wasn’t getting fatter anymore, and maybe was even starting to look trim again. Then, in early February, a cluster of odd changes occurred. Berry went lame, once at home and once in obedience class, where the instructor pointed it out to me in a somewhat accusatory tone, as though I had hurt Berry. He seemed to be scratching a lot in a non-specific way, but our house was hot and dry in the winter weather. Then, he seemed to develop the cold: his eyes were still red, he sneezed, and his nose ran. I wasn’t knowledgeable enough to check his lymph nodes, but because he was new to us, and I wasn’t sure what was "normal", I had decided to go back to VHUP.

Dr. Bissett’s news left me numb. I let them lead Berry off into the hospital for tests. From the pay phone in the lobby, I dialed Greg’s workshop and wailed into the receiver, "They think Berry has lymphoma." Greg gasped in disbelief; he had teased me that I was getting such a young dog from the rescue, that I would have Berry "forever". Greg came to VHUP and sat with me while I waited. I knew what lymphoma was, and I knew from Greg that it was fairly common in Goldens, but I didn’t know much more.

Canine Lymphoma

Cancer is uncontrolled cell growth that appears to be caused by genetic factors or changes in a cell. In some breeds of dogs, the genes that initiate the cancer process have been inadvertently selected over time. Cancer can also result from DNA change by hormones or carcinogens such as chemicals, radiation, or viruses. Cancer cells grow uncontrollably and, as a result, damage organs and systems within the body until failure occurs. http://www.marvistavet.com/html/canine_lymphoma.html

LLymphoma (lymphosarcoma) is a cancer of the lymphocytes, which are a type of blood cell, and the parts of the body containing lymph tissue – the lymph nodes, spleen, liver, and gastrointestinal tract. As discussed below, and in Chapter 3, there are several types of lymphoma, and which type your dog has affects the likely progression of the disease and key decisions about treatment.

Canine oncologists simply do not know what causes lymphoma. Certain breeds appear to be more susceptible; beyond that there is no agreement among the experts. We learned from our years in VHUP’s waiting room that there were lots of Goldens in their care – but Goldens are also a very popular breed. We also know of Airedales, Great Pyrenees, Labrador Retrievers, Shelties, and mixed breed dogs with lymphoma. Lymphoma is most commonly associated with middle aged and older dogs, but Berry was just 3 ˝ at diagnosis.

Symptoms of Lymphoma

Symptoms of particular types of lymphoma are discussed in more detail in Chapter 3. Most observable symptoms of lymphoma are difficult to discern, or are noticeable only when the disease is advanced. Moderately enlarged lymph nodes can be difficult for a layperson to identify without training. Decreased appetite, tiredness, weight loss, vomiting, diarrhea, lethargy, weakness, or excessive thirst or urination can have much simpler causes, and unless an odd cluster of symptoms occurs, as it did with Berry, you may miss them. Berry was tentatively diagnosed at VHUP that day based on external, physical signs: enlarged, hard lymph nodes in his neck and elsewhere, a prominent spleen, and his breed and age. His red, soft eyes and "dull" lungs were also noted that day. Interestingly, while these conditions were never specifically linked to Berry’s cancer, neither was noted again on physical exam after his cancer treatments began to be effective.

After the sick, numb feeling wore off, my next reaction was disbelief. They must be wrong: my dog can’t have gone from "apparently normal" to "suffering from a fatal disease" in under 15 minutes. And two of their findings – his swollen eyes and "dull" lungs -- had been identified in November and dismissed. So, when they returned Berry to me, I tried to expand the universe of possibilities by asking: "Based on what you’ve seen so far, what are the three most likely things my dog might have?" Their answer knocked me back down: "Lymphoma, lymphoma, and lymphoma." The deck was stacked: Berry's condition also had been reviewed by the specialists in VHUP’s Oncology Service. Dr. Bissett would call later that night, they said, with the results of the blood work (a complete blood count (CBC) and chemistry screen) and the lymph node aspirates, but in my heart, I knew the words we would hear. I made an appointment for chemotherapy treatment the very next day.

Arriving at home, I sat down at the kitchen table and called DC, an hour and a half away. "Berry has cancer," I said, "and we need to decide what to do." That evening was Cody and Berry’s last obedience class, and I didn’t care when the instructor reprimanded "those Goldens" for not obeying. A certificate for perfect attendance and my not bursting into tears were accomplishments enough. I was prepared for the inevitable message from VHUP on the answering machine at home. It seemed so unfair – Berry’s wonderful new life was being taken away before he even had a chance to enjoy it. We resolved to treat Berry, to give him as much good time as possible.

Staging, Diagnosis, and Prognosis

We were already scheduled to return to VHUP the next day for "staging" and Berry’s initial chemotherapy treatment. Staging, as further described in Chapters 3 and 6, is the process by which veterinary oncologists determine with greater specificity what type of cancer is present, and how advanced the cancer is. An initial staging always includes a CBC, blood chemistry, and urinalysis. Biopsies of affected tissues may also be done. Depending on the scope of the disease, an abdominal ultrasound, radiographs (x-rays), and a bone marrow aspiration may be performed to identify the presence of lymphoma in other organs.

Based on this information, the doctors estimate the likelihood of successful treatment and, if treatment is indicated, determine the optimal treatment program. That day, additional tests including chest radiographs (x-rays), an abdominal ultrasound, and aspirations (diagnostic samples) from his bone marrow and spleen, revealed that cancer cells were present in Berry’s external and internal lymph nodes, and in his blood, bone marrow, and spleen. Berry’s diagnosis was refined to "Stage V Mature (Small) Cell Lymphosarcoma." (See Chapter 6 for discussion of diagnosis.) This meant that, although Berry had few visible symptoms, the cancer was advanced – there is no "Stage VI". We were shocked: Berry had been evaluated by DVGRR’s adoption program in October 1999 and there at VHUP, just three months earlier, in November 1999. Berry’s life could be extended, probably 6-8 months VHUP predicted, with chemotherapy; without treatment, he would die soon. There was no time to debate – we had to act.

Treatment Begins

We began chemotherapy treatment that day – February 18, 2000. The plan was that each week Berry would come to VHUP for testing and treatment, using a treatment plan called a drug protocol (a group of drugs carefully selected based on the type of lymphoma and administered in a specific order and timing), developed by VHUP’s Oncology Service. We also made an appointment for Berry to be formally admitted to the Oncology Service. Because of the schedule of the Service at that time, the first formal consultation available was March 15 -- a month away, an eternity. It would turn out to be the worst month of Berry’s chemotherapy.

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