caninelymphoma-blog

[caninelymphoma-blog]

15. Toby passes to the otherside

It happened on Sunday morning 7 April just 5 days after his 14th birthday. Since the last post (Friday 5 Apr), Saturday was a total disaster where Toby couldn’t eat (even the smell of food was unbearable), couldn’t drink, couldn’t sleep (as  his breathing was too labored). we think he also suffered some kind of stroke or where his brain was affected due to lack of oxygen. This was the end of the road for the brave and sweetest little warrior ever known.. what a joy you’ve been to us Toby, thank you for coming into our lives. We love you so much and you know we’re so heart-broken, but we hope one day we’ll see you again. 

The trifecta of Lymphoma, Pancreatitis and Dilated Cardiomyopathy proved too much for Toby. The way we think about this is that Lymphoma would kill him by causing swelling in the spleen and lymph nodes, causing inappetence, breathing difficulties as well as bone marrow suppression leading to low RBC and WBC, making him weak and anaemic. 

Treating this then led to strong cardio-toxic drugs like doxorubicin that took a toll on his heart which ultimately led to DCM which causes fluid accumulating in his lung, massive breathing difficulties and oxygen deficiency. This leads to stroke and ultimately death from oxygen deficiency to the brain. 

In between, the dreaded pancreatitis which as mentioned in great detail previously, was a real spanner in the rims as far as his chemotherapy and wellness program is concerned. It not only derailed his chances of getting a 12-18mth remission, it caused him so much pain, weight loss due to inappetence, days of shivering due to fever/pain, caused by the inflammation in the pancreas. It basically reduced his vitality stats by 25% each time it happened. And once it’s happened, it can recur MORE easily. Pancreatitis can also cause lung damage - while unconfirmed in Toby’s case and not mentioned by any of the vets who treated him, i think given how he got it 3x.. quite a high likelihood there.

Toby took it like a real champion. He never complained (apart from his guaranteed shivers on the way to the vet), never put up a fight (aside from his post vincristin crazy antics.. it was the drugs causing him to go bonkers.. he would be difficult to control while Junie drove home). He was the sweetest boy on the countless blood tests, chemotherapy injections, IV drips etc. 

He played on most days, ate well on most days, with his signature “I shall rub my face all along your bed or the sofa to show how happy i am with the food”, and did his kick-kick routine in the morning in bed with us. At the end of it all, he was with us, surrounded by loved ones, held tightly in Junie’s arms, doing what he loves doing the most: enjoying a car ride... that’s when his heart and lungs gave up and his brain slowly shut down. His head rolled sideways onto Junie’s shoulder, no longer taking in the breeze as we drove home from the vet. Toby rejoined the angels that day, and could probably see us crying our hearts out at the inevitable outcome we dreaded for so many months.  

Dearest Tobes, please continue to look after us from above, and know that we think about you every day and hope to see you again, smell your unique kaya-smelling paws, and feel your super hot tongue on our faces. 

[caninelymphoma-blog]

14. Looking for that silver lining... But it isn’t there.

30 Mar - Toby slept a little better in his make shift oxygenated box the night before and Junie does an amazing job checking on him thru the night. I think she needs to rest up more or she will fall sick... same goes for our helper Bel and mom. Without everyone helping out, i don’t think Junie and I could have managed this.  

Today is also D-day as we head into Dr Tham���s w the intention of giving Toby a risky dose of L-aspar. Right now it feels like this is the only thing that can save him, but it might also kill him. We decide together that it’s for the best. Emotions run high.. The mood in the clinic is sombre because they know Toby is gravely ill since they last saw him.

He survives the shot and we head back home where he rests all day. His legs are still weak and we just keep praying. Just like how some customers came over and prayed over Toby, Joo Mee my cousin also comes over and she too prays over him with holy oil. We are so touched because she was so wonderfully positive and she stays to chat for a long time.

1 April - Toby’s the same, refuses to eat so it’s syringe feeding all the way. He hates it and so do we. We go for car rides and we pray he makes it to his 14th birthday tomorrow.

2 April Tue - Happy Birthday puppy bear. Korkor and jiejie have been sleeping in the living room with you because this is the best arrangement. It’s been storming a lot lately and the nights are often filled with thunder and heavy downpours. We try our best to sleep through it. it make us tired during the day but being there with you means everything to us. We went to see Dr Tham today cos Toby is running out of Vetmedin and that’s very important to keep him alive. we ask if we should try acupuncture. 

Dr Tham advises against going to Dr Tai for acupuncture as he recounted that one of his lymphoma patients had his cancer spread because Dr Tham did acupuncture on him and the circulation improved and so the cancer had a free pass to other parts of the body. We deliberate and decide to go anyway tomorrow. If we stay on this current trend relying on food and meds, it feels like Toby will get progressively worse and die anyway.

3 April - We wait ages for Dr Tai. It cost us 3 hours at her clinic but it was worth it, Toby seems brighter after his acupuncture session with her and he also had an x-ray to determine what’s up with his system. She thinks he still has pancreatitis hence she prescribes Famatodine (Pepcid) which I think should help him get better faster so he can start eating on his own. She prescribes 2 Chinese herbal mixtures (HQT and EG) Both Toby swallowed without putting up a fight. The other two supplements she prescribed probiotics and also Tricosamine which is a mixture of glucosamine, chondritin and HA. She noted that Toby had fluid in his lungs on one side and asked us to step up the dose of Furosimide to ½ tab instead of the ¼ tab Dr Tham recommended. She also recommended foods rich in potassium e.g potatoes, banana and mushrooms will help the increase of absorption of nutrients and helping his back legs too.

X-rays showed that the gaps in his spine were too small and it was causing him discomfort. His back legs became very weak because of lack of circulation and pretty bad osteoarthritis. His lungs are fairly clear, heart is quite large and pressing against his trachea hence the breathing difficulties and this means we have to make sure when we feed him he’s sat at a 45 degree angle so that he won’t aspirate the food that is fed to him into his lungs.

Abdomen looks fairly clear, and his rib cage is puffed up because he is trying to to maximize the space in there because he needs to breathe and he expands it like fish gills. So she also taught us some massage techniques that might help him gain mobility.

Later in the evening, we change the feeding plan and give him black chicken instead of regular chicken and some MCT oil.. and this is where it got bad. He threw up and then we couldn’t stop it even after going back to see Dr Tai the next day. She gave him a jab and oral meds but it didn’t help.

4 April Thu - Based on the recommendations of Joo Mee’s pet nutritionist, we feed Toby coconut juice, watermelon juice and carrot juice. He can’t hold anything down at all. He wants water so badly but he cannot keep it down either.

We withheld liquids and gave him his heart meds spaced apart by 30min blocks. He keeps it down until we give him  coco water and honey. We are so worried but we try to wet his mouth and let him sleep it off. He eventually pukes the coco water and honey as well.

5 April Fri-  In the wee hours of the morning, Toby drinks some water and vomits again, I give him the oral anti-vomit meds and it still doesn’t work. WTF? So at 8+ we made the call and brought him into Jireh for an IV drip. He looks so much better after being hydrated and we are thankful that he’s stabilised a bit but now comes the tricky part of re-feeding… With cerenia and the IV drip in place, Toby was able to hold down his fluids - so far we have given toby his medication (vetmedin, lanoxin, furosimide, famatodine… for food he has had mussel powder, convalescence just a bit.., chicken and parsley, watermelon juice as it’s a diuretic). We space out the feedings and it takes up to an hour to finish it. He goes out to pee and his pee is evidently held in as the stream of pee looks string thin and forceful vs. his usual jetlike spout. Likely due to the IV, consumed fluids and diuretic medication.

We feed again just past 9, he’s given Vetmedin and left to rest for 30 mins. And then we followed up with super diliuted banana and chicken blends. Then he’s also given his antibiotics and steroids both which we skipped yesterday because he could not hold it in.

We really hope he keeps it in this tonight, seeing that he was given Cerenia at 9ish in the morning and now it’s a good 12 hours since then. His eyes are still gooey and Junie cleans it regularly and put both antibiotic eyedrops and the eye gel. He was given quite a fair bit of fluids so he may wee himself tonight but we don’t mind, he’s the best boy ever and we can always clean up after him no matter how tired we are.

June: His nose is also super dry and today I thought it was dried up food and I tried to peel off dried skin. Oof! That must’ve hurt him, I’m so stupid! Gonna rub more coco oil tomorrow to help him.

WHAT WOULD WE HAVE DONE DIFFERENTLY

Stick to “safe” food and don’t risk complications. 

Understand that the entire system requires delicate balancing, so when 1 function is compromised, it usually causes other issues. when 1 drug is used, there are side effects and it can overall cause other issues. 

Recognize that certain bodily functions such as the liver, plays a critical role in overall health, as the liver is primarily responsible for metabolic processes, absorbing nutrients, and also detoxifying. a healthy liver helps with overall recovery. We were very late in recognizing this and probably should have paid more attention to this. 

[caninelymphoma-blog]

13. I blame myself

25 Mar Monday - Brought Toby in to Dr. Tham as he was really weak in the knees, not eating, and seemed to be shivering from pancreatitis. He gets some pain relief medication and we take him home. We continue to feed him and he manages to keep his food down. 

26 Mar Tuesday was worse - no appetite. no energy. In the afternoon we decide to take him to Jireh again to get IV catheter and drip hooked up so he stays hydrated. They gave us broad instructions of 1 drop per 7 seconds in the day, and 1 drop every 12 seconds at night. Toby rested and i let the drip go at 1 drop per 5 seconds or so, as i felt he needed to get more fluid in his system weakened by pancreatitis. ... and we started noticing some breathing abnormalities in Toby - shallow, rapid, and he was unable to relax for even 5 minutes. This started at about 7pm when Junie came home - after a whole night of fusssing around what to do and how to make him more comfortable, (IV drip was slowed down slightly .. somewhere around 1 drop every 10 seconds) we take him to Companion vet at 1am due to major concerns of his labored breathing and the fact that he looked completely exhausted.

27 Mar Wednesday 1am ~3am: consulted with Dr. Don who helped put Toby into an oxygen cage. Through numerous tests we ruled out fluid in lungs due to overdosage of IV fluid, lung cancer, low RBC. In the morning at 9am we returned with mom to see Toby, he seemed a little more rested but breathing continues to be labored. Further scans of his lungs and abdomen showed nothing. Eventually a heart scan was done at about 1pm and we were told that Toby clearly has Dilated Cardio Myopathy (DCM) which is likely caused by repeated chemotherapy (Doxo) and pancreatitis. 

Earlier we also ran a test for ionized calcium that showed Toby as having low levels but the unionized calcium was fine. Doesn’t seem to be the lead cause. Dr. Kenny at Companion informed us that DCM is not curable but can be managed to yield a few more months of relatively good quality life.

Vetmedin vasodilator and fortekor Ace inhibitor are heart medication that can help. Toby started on this today. 

Treatment for DCM

Diuretics

ACE inhibitors (vetmedin, 2.5mg fortekor 5mg)

Digitalis glycosides

Vasodilators

Bronchodilators

Pimobendan (inotrope + vasodilator, calcium sensitizer, PDE III inhibitor)

Taurine enriched food - dark meat

Calcium supplement

Treatment for chronic pancreatitis

low fat food - tofu, chicken breast, cooked veggies, turkey meat,  low fat fish, even carbs like rice... 

Pain management - Methadone

Treatment for Lymphoma (depends on neutrophils and WBC) 

L-aspar 

Antibiotics

Prednisone

HBOT

28 Mar - we left him there at 3 am and went home, then went back around 1230 to check on him. he seemed a tiny bit better. We had to hatch a plan to bring him home. His oxygen dependency meant that we had to create our own oxygenating living environment for him. We used a large ikea box drilled with holes to enclose Toby. We borrrow an oxygen concentrator from a company called ERIKG that specializes in CPAP supplies. it costs only $100 a month (but some dodgy vets will charge you $50 for 2 hours of using an equivalent of this... doesn’t make sense). They delivered it to our home. The machine works well and effectively let Toby relax a tiny bit. 

But him living in a box isn't a solution. He was initially very angry about it and tried to jump out of it, in spite of how weak he felt. We do more research and highly suspect that the nodes that have grown aggressively is causing breathing difficulties too. if anything it is also causing his lack of appetite and swollen mid section. Very similar to when he almost died at gentle oak. So on 29 Mar Friday Junie goes over to Dr Tham who agrees that giving Toby another dose of L aspar may be helpful. We syringe feed Toby on Friday to prepare him for Saturday L aspar. Robert visits him this night and receives a bunch of tail wags. Bob is quite emotional. Thanks Bob and Chuck you're great pals and buddies to Toby as well. 

WHAT WOULD WE HAVE DONE DIFFERENTLY 

I can’t shake off the thought that the accelerated IV drip may have caused additional strain on Toby’s heart. It haunts me and i feel like a complete idiot. I wouldn’t know what to advise ... but to simply BE AWARE of the risks. I blame myself and somedays it causes such pain to me, it’s difficult to describe it. 

https://www.nhs.uk/news/medical-practice/nice-issues-warning-over-dangerous-iv-drip-use/

[caninelymphoma-blog]

12. Toby refuses to let cancer get him down

week leading up to 2 Mar

Toby seemed stronger too after feeling not so good for a week. This week has just been great. Playing lots, full of energy, yelling at our helper for wiping his bird after a wee. He had a lighter chemo today after that last rescue protocol chemo almost a month. His bloodwork looks good too and he keeps wanting to play every night now especially when we’re in the middle of dinner!

3 Mar - Toby is fine in the morning but not much appetite. Didn't eat anything apart from a few kibble. We take him out for a car ride and to our regular cafe joint for coffee at 1145. He came home about 230, refused to eat, slept instead. He comes out and chills with us in the evening but starts shivering around 8 at night. We realize he may be badly affected by the vincristine like old times but also can't shake the possibility that pancreatitis is back. His temperature is 38.8. His weight was 6.9kg the day before. No doubt it's going to decrease further. 

4 Mar - One month after we had an issue with the pancreatitis, it's back again. Right after he was given a strong dose of vincristine, he held it off for a few days but then went into full fever mode on the third day. We iced him from 8pm to 2am and it wouldn't stop so we sent him into Companion once again but they didn't hospitalize him. They just gave him pain meds and the shakes were back again the next morning.

We had to admit him for two days at Companion vet. It was so painful leaving him there. He was feeling so angry with us and he also refused to eat so they had to force feed him. Finally I decided to bring him home because I figured he wasn't eating from stress and the moment he got home, he begged for food. Right away he ate the black chicken mom had bought for him!

We started him on  HBOT again to help w the pancreatitis. Hopefully it helps somehow. 

11 Mar - Went to see Dr Tham because his nodes were getting big and hard. We started on a modified LOPP protocol but as of today, we know it's not really budging so we have to start cyclophosphamide tomorrow. He's been shivering some mornings after breakfast and Dr Tham said that's a sign of him not having fully recovered from pancreatitis. Lomustine doesn’t seem to have any effect on Toby. Dr Tham always states depression as one of the causes but he’s so freaking happy! He plays a lot in the mornings. Always wants to be a punk and do the things i tell him not to. 

Went for a car ride last night cos he was feeling crook in the middle of the day, and he kept going back and forth in the front and back seats of the car, then he stopped cos he got stuck. He looked at me with the silliest of grins and started wagging his tail cos he was dangling from the backseat and the arm rest. I LOVE THIS SILLY COW SO MUCH! - Junie

21 March 2019

Lomustine aka Ceenu didn’t work at all despite the higher dosage. We’ve been taking him regularly to HBOT to help his pancreatitis but he still shook most mornings. We administered both pills of Cyclophosphamide and it’s has helped reduce the size of the nodes, he’s got an appointment with Dr Tham tomorrow at 11am but before that I wanna take him in for HBOT so that he gets as many sessions in as possible to help his tum! Cyclo has made him lose his appetite but he was also on pred and we just ran out so we need more tomorrow. Hope he’ll feel better as the days go on. I wonder what’s next after Cyclo. I wonder if Vincristine will still fuck up his healing tummy. Can he go on low dosage of L’aspar?

22 March 2019

Toby had a blood test today, his RBC is down and WBC is also down. All this is because of Cyclophosphamide naturally. Had a long chat w Dr Tham today cos he had no patients after us. Picked his brain about the LOPP protocol and he said the last dog he treated was actually 16-17 years old and was quite stable but his nodes flared up so they decided to use LOPP. The nodes did subside but his whole body shutdown at the same time. He declined very quickly. So Dr Tham is of the opinion that this isn’t worth it. He said that Toby’s current treatment is way off course. We need to tweak until we find something that works well and stabilize his condition again. So now we are testing whether it’s the Lomustine and Cyclo combo that works or if we can just do a much lower dosage of cyclo if it can work its magic alone. Next Friday, we’re gonna do a low dose cyclo to see if it works then we’ll be able to tell if we can just just one drug of if we have to use a combo.

Toby vomited a little this morning but he ate his brekkie and he’s in relatively good spirits. Dr Tham suggested that he takes some gaviscon for humans. He ate the Happy Dog food which he seems to like so… we’ll see. It’s back to HBOT again tomorrow morn. Fun fact: Dr Tham said his oldest living cancer doggo was 18 years old. Jack Russell. Toby has a long way to go!

[caninelymphoma-blog]

11. Countless trips to the vet - but worth it!

29 Jan 2019

Toby was due for a low dose vincristine today but couldn’t stop shivering the whole night. We suspected pancreatitis and we were right. He’s on a raw keto diet but without sufficient exercise and occasionally cooking the food to counter his inappetence, Toby lost one of his cramp-ons while trying to overcome the treacherous Mt.Lymphoma.. he  slipped and fell further... and this 2nd episode of pancreatitis was essentially a fatal error on our part. 

Dr Tham also said that his kidneys are showing signs of wear. Mostly due to age and also Long term chemo. However he said that he’s doing well just on vincristine along as a Low dose pulse therapy. Most dogs need stronger drugs. Perhaps it’s the herbs, jiaogulan, HBOT, wasabi sprouts. We’ll never know. All I know is that he’s doing so much better now than he was last year. His happiness, energy and all are still there if not for pancreatitis. 

We reassessed his keto diet to see if we can avoid this happening again  because technically half his food is cooked because we did not wish to give him raw liver. We continue to do juicing but remove the flax oil from the mixture (could have been too difficult for his liver to handle).

Currently Toby is on an IV drip cocktail of B12, blood booster, he’s on a painkiller called methadone that makes him Super sleepy even though the dose is tiny. He’s also on 40mls of IV antibiotics a day. I hope the cancer will stand down while he recovers from this episode. I feel the nodes, they’re very tiny but we need to to everything to keep them dormant. 

1 Feb  

We had to return to Dr Tham on Thursday cuz Toby was on path to recovery and even ate a whole meal of low fat dog food to help him recover. He started shaking again though so went back and this time  get an additional dose of antibiotics Extra note: Dr Tham didn’t want him to stay over and said it’d be more comfy for Toby at home + their clinic wasn’t well staffed. 

Sunday 3 feb: Toby kept shaking non stop. We went to Companion and they were very professional. They managed to get whatever was causing toby’s fever under control and even fed him. I was so reluctant to feed because I felt that was causing his pain but they handled it well. The assistant speculated it could be the catheter that caused the infection. Dr Kenneth helped Toby out and he got better after switching catheter from left to right paw and lots of fluids and hill science diet I/N for sensitive tummy. 4 Feb - Toby came home and was able to join us at reunion dinner. He was super playful and happy. We give him big kisses and our family is together again. 

“More sleep please! fighting pancreatitis and cancer is tough work... “

8 Feb - He had a CBC blood test and L-aspar (3rd dose) . He seemed tired and very very sleepy. Wonder if it’s the antibiotics or is he just still in recovery mode. CBC looks good. Nothing too serious but with the food Companion was giving him, he seemed to have more energy and when i switched him back to keto, he seems a little tired. However the Hill’s diet they gave made him constantly lick his paws and his nodes grew back fast.   Currently Toby’s been put on antibiotics for a week to clear up whatever is left of the infection and then he’s also on probiotics specifically for cancer doggies which should be good for him.

The whole week that Toby didn’t eat much, the nodes didn’t grow back at all. It was barely detectable and this tells me that food is very important because it will feed these bloody cancer cells if we give Toby foods high in glucose and glutamine. 

15 feb - Toby went for a blood check back at jireh and results are quite good. We celebrate a little. Probiotics for cancer dogs prescribed along with a restock of marbocyl. Due to pancreatitis Dr Tham took precaution not to prescribe prednisone as it may cause further weakening.

Dr. Tham reckons this cancer looks more like B cell. Dr. Lee at Gentle Oak speculated that it was likely T-cell given how aggressive it was. Not that it actually matters whether it is T-cell or B-cell (though if you want to know, you can ask for a biopsy to be performed). There’s a very small range of treatment options that can be deployed, to help fight aggressive cancers. We heard separately from other vets at Companion that pretty much none of the cancer treatments work for T-cell and dogs would just die rather quickly. But in Dr.Tham’s experience, a dog which had confirmed t cell went into remission after several months of vincristine. 

22 Feb 2019

Vet visit today was to get Toby back to his vincristine pulse therapy but his bloodwork was good and RBC is up and no growing nodes so we decided not to go ahead w any chemo today. 

I mentioned Toby’s fussiness w food, recent not so happy moods. He said fussiness w food can be learnt. We always give him what he wants and he figured if he holds out he can get kibble etc. Either that or the chemo and antibiotics has done a number on his tastebuds and he doesn’t feel like anything is good enough anymore. 

Shakes in the morning means Low blood sugar and as they get older it’s harder to control the shakes. Lower tolerance. 

Curved back could mean that there’s still traces of pancreatitis left. Hence the hunch. So we have to be very vigilant and not feed rubbish cos it does go away so quickly as they age. 

Moodiness could also be caused by a hormone imbalance. He might need iodized salt. Like a pinch of it to help his thyroid. It might work after 3-4 days. 

So we’re going in again on 2 March (Sat) for blood test etc unless his nodes come back earlier then we gotta hustle and get in earlier. 

2 Mar - Better results. RBC is up. Nodes are back. Vincristine higher dose to kick it back. Monitor neutrophils level to figure out if things are getting worse. Still no pred. His appetite not that great. 

WHAT WOULD WE HAVE DONE DIFFERENTLY

- important to train your dog to understand medicine time vs. feeding time. Very often we would try to sneak in medication into his food. When he tastes the medication thinking he’s eating his favorite food, he suffers a negative experience and associates it with that particular food and suddenly, it’s no longer his favorite anymore. We saw Toby switch from chicken to beef to liver to kibble, all because we kept trying to hide bitter medication in his food. (we typically crushed it as he usually spit out whole capsules)

- Separating medicine time means that you’ll need to syringe the medicine into his mouth and get him to swallow it. he’ll associate that nasty feeling with the syringes and not his food. that way, at least you’ll still be able to feed your dog what he needs to eat ! Remember that nutrition is just as important as medication. 

- Growth of nodes definitely accelerated by processed food high in bullshit ingredients, but made to taste irresistible to dogs. We saw that correlation first hand. Never feed your dog non-natural treats. Look at home-made treats: perhaps get a dehydrator and make beef jerky or dried fruit snacks.

[caninelymphoma-blog]

10. Toby makes it to Christmas and New Year!

23 Nov ~ 4 Dec. Toby has been very genki and in good shape with his nodes barely noticeable prior to our departing for the trip. However upon returning we noticed that it’s back. Small and hard nodes. His appetite had been pretty good and we continue with the juicing and other treatments and supplements. We give him second dose of lomustine. Doesn't seem to be working well. 

11 Dec. Lymph nodes are back. Blood work shows that neutrophil and lymphocytes are low. Dr Tham decided to prescribe a different type of antibiotics that cover a broad spectrum. He is also prescribing a stronger dose of Lomustine. We need to monitor how he's doing. If Lomustine doesn't work we need to think about a different set of drugs 

18 Dec. Toby is in good spirits.  He peed the bed a bit but his appetite is generally okay. His weight is about 7.3kg last I checked. He feels solid and strong-ish. He jumps up and down the bed and stairs with ease. He wants car rides and plays kick kick in the morning in bed. However. The fuckin lymph nodes are growing again. Lomustine is not effective enough to fight this off unfortunately. 

21 Dec - toby's neck nodes have grown fast and hard. It may be that Lomustine is actually ineffective or it could be due to a lack of hyperbaric treatment that 10 days or so that we were away. We can't be sure. Another trip back to Jireh and doctor concurs that Toby gets L-aspar and vincristine. 

22 - 25 Dec its Christmas! We play lots with Toby who is doing really well thanks to the #2 dose of L aspar. We take a Christmas pic with Toby in his red knitted sweater. We have a Christmas lunch party on 23 Dec and Toby was in good spirits. His friends came to give him kisses and hugs - Robert, Chuck, William, Olivia, sid, mads… His lymph nodes shrunk significantly. His routine is now 3 meals a day, beef, marrow, liver, greens, sprouts, green juice. At night he gets some kelp. He gets HBOT twice a week but we plan to ramp up to 3x. 

29 - 1 Jan -  Everyone is kind and say Toby looks good. Toby also has good fun with Eric Marcus Elgin Tiffany coming over to give him hugs n kisses. He humps Eric 10 times! Loves it. I think he has a bit more time before the lymph nodes come back..based on last experience, it should start regrowing around 20 Jan. We may have to think about administering bit of doxo then though I think lomustine is not effective at all. 

4 Jan - going back to Dr Tham for a check up… Plan was to administer vincristine for maintenance.. Toby weighs in at 7.3

Week of 7 Jan - overall Toby is in good shape though his stools are tarry and wet. His appetite is back to being picky as he is not on pred this week. He still plays and begs for treats. He's looking very shabby this day and very cute 

15 Jan - Junie takes Toby for another visit with Dr Tham and it looks like his blood work is really good. His lymph nodes are tiny but seem to be coming back. Dr says to start on pred again. Tarry stools may be due to antibiotics build up. We leave on Friday for last min snowboarding. Toby gets a low dose of vincristine again today. 

Toby’s cough is still there. Especially after drinking cold water or playing on his back. He’s still eating decently, he’s now on a bunch of herbs including jiaogulan and we also give probiotics for his tummy. He still loves playing, he brought his toys out last night and played until his was tired. He was throwing his banana at Tasha and was so cheeky. His quality of life has improved a lot compared to when he was on the CHOP protocol, always miserable and poopy and tired. I really hope this works out well for puppy bear. 

So now Dr Tham has said that the intervals between L-Asparariginase is getting shorter and he doesn’t want the cancer to get resistant to it. So he’s gonna use vincristine low dose in pulse therapy and add on prednisone to ensure it works well and we don’t have to resort to big guns. 

Toby’s also been walking more and it’s good to burn off the excess glucose so nothing is left for the cancer to eat. Aiming to walk him every evening at 6.30 for 30mins at least. 

WHAT WOULD WE HAVE DONE DIFFERENTLY?

- definitely ought to be less concerned about the lymph node sizes and pay more attention to Toby’s blood work. 

- ought to have kept up on HBOT and less focused on Toby’s appetite. Fine if he doesn’t feel like eating .. until he wastes away too much obviously (that’s when syringe feeding has to come in). 

- We need to focus on creating positive cycles: HBOT, good keto diet, exercise, build up his immunity. every dose of L-Aspar is a great opportunity to kick off that cycle.

[caninelymphoma-blog]

9. Nothing makes me happier than getting Toby back to 100% health

23 oct So, no thanks to Dr. Lee, we managed to buy some time with doxorubicin (#5). Toby got better with doxo and fortunately did NOT require a blood transfusion. the lymph nodes shrunk. The size of his abdomen also normalized. However, within only a week, his nodes started to enlarge rapidly again.  We take Toby to Dr. Tham at Jireh vet. Blood test showed Doxo completely pummelled Toby’s WBC meaning he could be even more susceptible to infections. His RBC is up though and he’s looking and feeling a little better. Dr. Tham administered  L-Aspar (Leunase) Vincristine  Benadryl - antihistamine It was done via a catheter and he dispensed it over two sessions with a 20min wait in between to ensure he’s not allergic to the drug which is plant based. He also put Toby on preventive antibiotics, given how weak his immunity was:  2 new antibiotics (Marbocyl and Cephalexin) to be used together until the next visit. Hopefully they work well and the next time we see him, Toby will be ready for Lomustine - which is what someone over a podcast says to really help their dog who had a very aggressive lymphoma with various symptoms that sounded a lot like Toby’s.  We started Toby on bone broth and we’re hoping it’ll nourish him esp when the side effects kick in and inappetence is one of them.

We also started on feeding and rubbing him down w Frankincense and Myrrh but we did that before bed last night and his nodes got bigger in the morn. 

He’s also on green juice every morning, hoping that’ll help him a bit. We are also thinking of going back on the budwig diet to see if that'll help him, but he hates it. 26-28 oct - Toby is so much better after L-Aspar took effect.  Started playing some more, eating voraciously, and happy to go on walks. We need to walk him more and get him some exercise. Lymph nodes shrunk substantially. Looks like L-Aspar is amazing! 30 oct - Toby's RBC count hasn't changed since the last blood test a week ago, but neutrophil and lymphocytes are back up. His platelet count has skyrocketed due to bone marrow working in overdrive to create more Red blood, causing concerns of blood clots and possible aneurysm or heart attacks. Take ginkgo to help mitigate, says Dr Tham. To increase RBC take pork or beef liver. Due to non ideal RBC and HCT count (23%) Dr Tham advises against Lomustine right now. Needs to clear 30% before administering otherwise risk RBC / WBC crashing again which may require a blood transfusion. Appointment set again for next week Monday 10am to check blood count before deciding if lomustine can be given. Prescribed more antibiotics and prednisone (though daily dosage to come down to encourage more RBC). Can't feel lymph nodes at all ! which is an amazing turnaround.  5 Nov Monday - junie took him down but his blood work is still not great. RBC and HCT still just about 4.0x10^12/L and 25% respectively. Can't do Lomustine.  Antibiotics continue. Toby has a great week overall and very genki. Almost back to normal self. Lymph nodes still very small. 12 Nov Monday - blood work improves to 4.56 RBC and 29% HCT and Dr Tham relents and permits a low dosage of Lomustine. We are very hopeful that it will work. Due to the chemotoxicity of Lomustine we will need to handle Toby’s poop and pee with care. Monitor for puking and diarrhoea, lethargy and reduced appetite. His PLT count has come down - thanks to gingko - but can now go easy on it. Antibiotics will keep infections at bay in spite of low Neutrophils count, and no issue with expected side effect of Lomustine causing neutrophils to crash. He might also get depressed and will need more kisses. At certain angles I could feel a tiny bit of his lymph nodes on back hind leg. 17 Nov. Toby is pretty much OK. He has been on his usual routine of pred, Sam-E, antibiotics cephalexin, gingko every alternate day. Diet wise he's eating beef, liver, bone broth, coco oil, broccoli sprouts, toman fish, celery, spinach, Chia seeds, seaweed. Boosters are sanghwang, k9 immunity as treats, milk thistle (we usually forget) and some probiotics. We are also trying to make him exercise more frequently. His poop is now regular and not watery like how it was when he was on vincristine, doxo and cyclo. 

WHAT WOULD WE HAVE DONE DIFFERENTLY?

For once, i have nothing to add here. This part was great. We finally got things right, with guidance from Dr.Tham... Toby’s quality of life improved and he looked almost like the same puppy pre Lymphoma! we are so happy and loving every moment of it. We cherish these times by playing as much as possible with Toby and cuddling with him. He doesn’t crave the attention but he knows we’re crazy about him. 

[caninelymphoma-blog]

8. Ground Control to Major Tobes

I stopped writing these posts for a month or so.. couldn’t bring myself to re-live these memories again. It’s really getting harder. 

an excerpt from a post back then.

“Hyperbaric oxygen therapy involves Toby freaking out a bit and shivering initially, followed by non stop panting for an hour. It's supposed to be good for you Toby! Lots of treats and kisses for you when you're done! this has become a regular routine (sometimes 3x a week) and now he doesn't whine anymore - brave boy!”

So what does hyperbaric oxygen therapy do ? it’s basically breathing high concentrations of oxygen at 1.5x atmospheric pressure. You can google it, but the main takeaway relevant to cancer treatment can be summarized as the following from a podcast with Peter Attia and Dom Agostini:

‘What was obvious is that cancer cells have elevated rates of reactive oxygen species that they use for growth and proliferation…and it also fuels metastasis and invasiveness of cancer cells. And because they overproduce oxygen free radicals in the context of high oxygen, you can push the cells above their antioxidant potential and then trigger apoptosis.’

Well, at least that was the theory behind it... we didn’t get that far, because basically he wasn’t in Ketosis at the time and the cancer was mounting another attack and Toby lost 0.7 kg in 10 days. Here’s what happened.

3 oct - Toby's appetite is not that great. His tummy feels bloated. Worried about spleen infection and more lesions. We decide to give him flax seed oil again. We have to cut back on his meat intake and try our best to get him into ketosis.  Will test him for ketosis today. The strip shows that he had only trace amounts. We give him only 30g of meat a day. 4oct - Toby is at the vet and his x ray results show that his lungs are clear. No cancer there. Dr Lee puts him on something to preempt his fever and administers vincristine for second time. (Cyclo, vinc, vinc). Toby gets another fever and junie puts ice on him again and his temperature hovered around 40 deg c 5 oct - started giving toby jiaogulan tea. Also started on K9 again. Toby's appetite sort of deteriorates over the days. It's strange as usually it comes back quite strong after the 2-3 days post chemo. 13 oct - sigh. Where to start. 7kg. His weight plummeted by 10%. Not sure if it's the diet or the cancer. He looks tired and he’s not eating much. Toby's blood work is very poor. Dr lee tells us that the cancer ridden spleen is acting as a shredder of red blood cells and driving down the RBC 3.33 and HCT 21%. He's anaemic.  This means oxygen is not being adequately carried around the body and it would impact cell health. We ask Dr. Lee if she had L-aspar or Lomustine, as these came up during our research as good rescue protocol drugs. She said that Lomustine is a drug that most vets no longer use in Singapore, as there was some issue with it. she said that we will need to get the oral tablets from private hospitals. Vets don't carry them. Junie steps outside and makes call to Jireh vet - who confirmed that they do carry Lomustine. A colleague of mine switched from gentle oak to Jireh and told me specifically that Dr. Tham at Jireh administered Lomustine to her cat, and it worked wonders. We were tempted to go straight to Jireh, but Dr.Tham was away that week, not available for consultation.

We had to make a call on what to do in the interim. Dr. Lee simply shrugged and said that Toby lasting this long is already a good result. She was rather resigned to “it is what it is”. We were not going to let our puppy fade away like this though. So instead of going thru cyclo today Junie and I decide to go with doxorubicin (#5) instead as it was critical to push back the cancer and buy Toby a bit more time while we work through other solutions that Dr Lee couldn’t help with.. it was clear to us that none of the other drugs (vincristine, cyclo, prednisone) were working - yet doxo was very effective before. Dr. Lee advises that it may be too much for Toby to handle another dose of doxo (5 is the max), and that we should be prepared for the worst. Dr lee also cautions us to prep a blood donor for DEA 1.1 negative as ideal. Dog above 20kg weight. Needs 240ml (small bag). A blood transfusion may be required over the next week. 

We bring toby home and he's still in good spirits.. We heard that a lymphoma afflicted cat survived on kibble for the last 1+ yrs. so giving him a bit of kibble now n then is probably ok??? As long as he eats. Toby eats a bit of salmon and some K9, and 2 kibbles and bit of chicken. He throws up some phlegm later. Fever onset. But sort of mild ish... compared to the vincristine previously. His max temp hit 39.7. Iced him for a bit and he seemed to have recovered.

To celebrate life we bring Toby to Macritchie and catch the most amazing sunset

WHAT WOULD WE HAVE DONE DIFFERENTLY

- pretty obvious, but getting our little pupper into Ketosis was absolutely key, and we missed that. The HBOT (hyperbaric oxygen therapy) would have been much more effective at killing off cancer cells if pupper was already in ketosis.

- again very obvious, but getting a second opinion is always good. We found out about Dr. Tham too late. The 5th doxo ultimately led to his heart weakening. Avoid doxo as much as possible. 

- We should not have assumed that Dr. Lee knows best. In the end, all vets are human beings and limited by what experience they have. Do not confuse expertise/capabilities with google reviews. 

[caninelymphoma-blog]

7.  Was it a #goodfight? no such thing as a good fight..

All of July was really good. Toby had a great time with us and his coat was a stark contrast of brown against his usual white / cream coat, due to the doxorubicin causing old fur to fall out and new brown fur to grow. We give him epsom salt hot baths like this one to help with his circulation and “detoxification”. Toby tolerated this and gave us a bit of the stink eye, but he knows we do it out of love.  

“Yeeeeesssss ... i like it out here!”  <-- Macritchie offers beautiful sunsets.

“I look happy but i really don’t want to be here with these 2 psychos who need to be restrained!!!!”

27 Aug - After 2 months of bliss, almost like nothing was ever wrong with Toby... His blood test results came in after a routine check, which confirms that the cancer is coming back. Toby never truly went into remission. The cancer simply was too strong / resilient. Perhaps along the way the CHOP protocol was administered wrongly - he had a couple of infections that got in the way and delayed the start of doxo - perhaps that delay led to inefficacy in reducing cancer cells?  Toby’s submandibular lymph nodes have been growing. His RBC and WBC count is low. He's back on blood stimulants and immunity booster. San Hwang mushrooms (very expensive! i don’t know if it was effective at all !) prescribed. 28 Aug - Doing an ultrasound today to check if cancer has metastasized to other parts of his body. Toby had to starve all day. Poor puppy threw up bile at lunch time.  1 Sep - brought toby down to gentle oak as we found a large swollen lymph node on this right collar bone area. We are in shock. how did it grow so big? Did another blood test and started vincristine today. Collected San hwang today. Decided to stop K9 immunity as apparently maltodextorine can be bad for cancer growth?? we are in a daze, flurry of information / unsubstantiated, random and confusing. It’s a nightmare. 3 Sep - Toby is shivering in the morning and things don't look good. He has a temperature. Junie rushes him down to gentle oak and wait for 2 hours before they administer IV fluids and antibiotics as he seemed to have caught an infection. His temperature was 40.5 deg. Normal would be 38 deg. Toby stays there for 6 hours and We pick him up together at end of day. Toby seemed a lot better and in good spirits then. Junie believes he had an infection leading up to the vincristine, evidenced by the cough. The vincristine weakened him further and it started to manifest. Lesson learned is that once he starts coughing, it means he is likely down with some sort of bug due to low immunity. 7 sep - Toby is in better shape and will be undergoing a tuned back CHOP with no doxo, recommended by Dr.Lee. He seems to be doing ok. Bit of trouble getting him to finish vitamin c IV injections. Seem to hurt him every time it goes in. 29 sep - 7.75kg. blood test shows WBC is up slightly but RBC is still badly down. Dr Lee recommended x ray for chest next week and also cut down prednisone by half. Toby gets vincristine again. Toby shivers at night and we realise he has a fever. We use ice to cool him down and manage his fever while taking periodic measurements. It went up to 40 deg at its highest but later at 2am Junie manages to get a reading of 38.8. It's a bad bad night but Toby lives. 30 sep  - Toby seemed a lot better in the morning. No more shivers. we start on hyperbaric oxygen therapy at animal recovery centre . First session 30 mins. 1.5x atmospheric pressure with high %oxygen. It gets hot in the chamber so someone needs to be present to monitor. There's an ice pack to cool toby. Toby paws at the plastic trying to get out. He whined as well as it was pretty daunting and unfamiliar for even a brave pupper like Toby. I stayed by him for the  full hour session and realised he felt better if I hovered over the plastic cover and if he hears my voice. We schedule a follow up session for Thursday morning. WHAT WOULD WE HAVE DONE DIFFERENTLY

oh... where to start. This is the hardest post so far, as things really just started to get bad from here. Writing this is like re-living all of it. The first 6 posts were written quickly and purposefully. This post.. just made me angry and sad. 

- ANTIBIOTICS to pre-empt fevers!

- CALORIC RESTRICTION TO STARVE THE CANCER to increase efficacy of hyperbaric treatment

- Consider using RAPAMYCIN, working with your vet, to help improve immune function (esp. in aging dogs) and also to help improve heart function and fight off cardiomyopathy

- CONSIDER USING OTHER DRUGS instead of flogging a dead horse with the largely same, albeit slightly modified CHOP protocol . There’s L-Aspar, Lomustine that are proven to be effective in many cases. L-aspar is a natural occuring compound with limited side effects.

Toby in his favorite spot, looking perfectly content. 

[caninelymphoma-blog]

6. Brown coat > White coat?

1 June - it took toby a whole week for the diarrhoea to stop. Last night it rained heavily from 230 am all the way to the morning. He didn't have to go to the bathroom thankfully which meant we were spared from being soaked in the rain in the dead of the night. We continue to give him K9 immunity. 

“Don’t feel so good... so Billy takes me out to get some air and a bit of a walk.. i love car rides!”

6 June - Junie takes Toby to the groomers. After taking off his wispy coat Toby shows his puppy brown colours underneath. The texture is a little rougher than his usual, and it is dense and beautiful. We have a good laugh and take some pics.  

Um... Junie did you bring home the wrong doggo?  7 June - vincristine shot. Dr lee says we will need to do one last round of the triple shot (vinc, cyclo, doxo) before he gets restaged or off chemo for a lil while. Pending blood work and analysis. Toby gets diarrhoea again. Looks like yogurt is key to him feeling better / replenishing his gut 10 June - Toby finally starts playing again - things are good for a while... he has great quality of life 21 June - cyclo shot. Gets a top up of the immune booster oral pills. Should last a while. 5 July - vincristine shot again. Toby takes it relatively well. Just the usual diarrhoea that ensued. 19 July - dreaded doxorubicin (#4) shot and his last shot on the bi-weekly staging . Toby begs to go home. Dr lee is super busy and the wait is longer than usual (1.5 hours today.. wtf...) 23 July - refused to eat on Sunday (day 4, if day 1 is doxo) but okay with some kibble and 2 kale n beef treats. Monday continues to be challenging but he woke up in a good mood. Drank some water after eating treats.  26 July - noticed that toby undercoat is turning white again.  Overall he’s doing great. Spends his days lurking at the window by the pool, waiting to ambush his #1 enemy - an elderly and astute black and gray Schnauzer who goes by the name “Niao Dan”. 

“Don’t distract me! that snob of a doggo is coming anytime now.. i can feel it... “

[caninelymphoma-blog]

5. Doxorubicin - the slow and silent killer

“I insist on sitting on my KorKor’s lap while he drives. Who cares if it ain’t safe?”

22 Mar: Toby gets vincristine. 

23-24 Mar - Toby vomits and loses his appetite for a couple of meals. Usually breakfast. It's hard. He still eats the beef though. Otherwise he's his usual self and plays, goes on car rides and walks.  29 mar - Doxorubicin (#2) administered at Dr. Lee’s. He seemed ok all day and after getting hit with doxo he seemed to stone a bit thru the evening. He went to bed earlier. Looks tired. 5-6 Apr - Rest week. no chemo. His appetite worsened again after doxo earlier and he lost weight. His diarrhoea came back. We started giving him some yogurt to help improve the probiotics in his tummy, which was endorsed by dr lee. Toby liked yogurt with his chicken but continues to be picky with raw beef. 12 Apr - Toby gets blood test and vincristine. Dr lee says he is in much better state and his lymphocytes (?) count was a lot lower and healthier - first time in a while.  19 Apr -  Rest week. We take the opportunity to fly to Komodo for a 5 day trip. Toby's tail fur is regrowing in a dark brown! 26 Apr - Toby gets cyclophosphamide drip again. Seemed alright but he has diarrhoea on Sunday night 11 May - Toby gets vincristine. Manages it relatively well over the next few days. 24 May (Thu) - Toby gets a nasty shot of doxorubicin (#3) along with histamil and metomide which is used to help with the side effects. Toby was fine on Thursday and Friday night. We introduced deer antlers to his diet which he loved, and chewed on it for the glucosamine and collagen. It cleaned up his teeth and breath really good. But on Saturday and Sunday his appetite was very poor. Sunday he hasn't eaten anything all day. Will need to monitor closely. He gets diarrhoea and basically keeps us up a lot every night. He had about 3-4 trips to the backyard thru the night.   28 May (Mon) - after not eating for the whole of Sunday, he finally grabbed his deer sinew and chewed on it this morning. He got thirsty and drank water. After that his appetite appears to have normalised. He ate his lunch and he rubbed his face on couch as usual. Lovely boy. His diarrhoea continues though.

WHAT WOULD WE HAVE DONE DIFFERENTLY

We ought to have taken the side effects of doxorubicin much more seriously! With cumulative doses, dogs will die of cardiomyopathy. This is pretty much proven. Limit use of doxorubicin by stretching it out as much as possible. Every hit seemed to take a huge toll on Toby’s vitality. We should have relied more on METABOLIC TREATMENT (more to come in later chapters) of cancer as opposed to relying on a drug that kills fast dividing cells pretty much indiscriminately, while the toxicity maliciously accumulates, hidden away, until it is too late. 

In case you didn’t get the gist: once congestive heart failure occurs, it is really the end. There isn’t any quality of life. Your dog will be spending all its energy literally just breathing. 

Doxorubicin (Adriamycin) cardiotoxicosis

Doxorubicin, an antineoplastic agent of the anthracycline antibiotic group, is used in the treatment of lymphoma and other neoplasia in dogs; cardiotoxicosis is the major factor limiting its use. Acute cardiotoxicosis appears to be mediated by peroxidative injury or expression of cytokines. As well, binding of doxorubicin to nuclear and mitochondrial DNA causes blockage of DNA, RNA, and protein synthesis. Chronic doxorubicin cardiotoxicosis, which may be due to decreased protein synthesis as well as altered divalent cation concentration, occurs in dogs given cumulative doses. Congestive heart failure occurs in such dogs; microscopic myocardial changes consist of myocytic vacuolar degeneration (“adria cells”), myocytolysis, myofibril atrophy, and fibrosis. The cardiotoxicity of doxorubicin is reduced when administered as a pegylated liposomal form.

[caninelymphoma-blog]

4. Pancreatitis is that awful ex you never want to see again

https://en.wikipedia.org/wiki/Pancreatitis15 Feb 2018 - Finally Toby is cleared to start on doxorubicin. His nodes have been growing back again, even after vincristine and cyclophosphamide. in particular cyclo did not seem to have much effect.  It is Chinese New Year - Junie and I are in PJ with relatives for only 2 days 1 night, and Junie’s Mom has to take Toby to the vet. We made contingency plans in case Toby has a bad reaction and we have to fly back immediately.  Over the following week we note that nothing bad or outside the ordinary (reduced appetite for a couple of days, combined with bit of loose, tarry stools).  Doxo is known for cardiactoxicity and causing bone marrow suppression so we feared the worst. The side effects did not surface at this time. Toby is rested for one week from chemo as planned. His lymph nodes shrank substantially so the doxorubicin was very impactful 25 Feb - It’s a Sunday and we throw a party for close friends and relatives .. to enjoy mom’s homemade Peranakan dishes for Chinese New Year. Toby has a great day but he must have eaten something he shouldn't. We suspect one of the guests gave him some food. Junie had also fed him a few emu treats with flak seed oil..  More than the usual. He developed acute pancreatitis and could not sleep. He shivered all night and had diarrhoea 3 times. We felt for the first time that he could die .. it was so painful seeing him this way and we were tormented by the possibility of losing him

The next morning we rushed him to the vet at 930am at Barkway (because it was closest). They did a blood test and failed to pick up on pancreatitis. As they did not know what was wrong with Toby, we sent him to gentle oak vet afterwards where he was properly diagnosed and hospitalised for the day. Dr. Lee was visibly annoyed that the other vet failed to pick up on this. Toby continues to shiver through out, but we can’t tell if it’s from the pain, or the usual fear of being at the vet clinic 27 Feb - 1 Mar: Toby spends 3 straight full days at gentle oak on day hospitalisation basis where he gets painkillers, an IV drip with metronidazole, antacids, probiotics, Wei Ling San, immunity boosters, licorice and marshmallow. Doctor Lee said no more beef in the interim. All chicken breast and a bit of rice. Easy on digestion. I still gave him k9 immunity though to help boost his immunity. He loses about 10% of weight and goes from 8.3kg to 7.5 ish kg but actually looks healthier with much less bloat in his mid section (his spleen was affected by the cancer0, and is able to sleep at night without the shaking. Pancreatitis took a lot out of him as he didn’t eat at all in the first 2~3 days and was kept in a cage at the vet so his leg muscles weakened. By this time, i had started being a lot more conscious that Toby may not be with us forever. Whenever the opportunity arose i would work from home or leave from home a bit later than usual. Thank God for my understanding employers who’d let me make it up at my own terms. On May 3, basically a whole week after he had pancreatities, Toby was finally his usual self and able to play his “kick-kick game” with us in the morning. We were overjoyed. We reintroduce veggies into his meals again for the antioxidants. We continued giving his food and mixing it with digestive enzymes.  3-4 Mar - it’s the weekend ! Toby goes on walks at Bishan Park, Macpherson and Macritchie. He's in good spirits and is able to walk decently without signs of getting tired. He got a shower on Sunday afternoon and threw some crazy tantrums.

This is Toby’s “come on, enough! i gotta go home now~~ and check on Junie!”

8 Mar - Toby’s in good spirits until he realises we’re headed to the vet. Neck nodes can’t be felt but popliteal nodes still there. About 1.5cm all round. Dr Lee did a CBC. Results came back good so she administered Vincristine on him right away. His RBC is good too. Immediately after Vincri he gets crazy angry and makes it difficult for Junie to drive him home (so usually Junie will bring someone along to keep him under control!). As usual. It’s a side effect. Dr.Lee says that Toby will go thru a whole cycle of CHOP again (Vincristine, Cyclo, vincri and Doxo, with pred..) Maybe after that we can depend on natural treatments, she said...  15 mar - Toby had a long 30 min cyclophosphamide drip administered. He looked tired and fell asleep in the car. But woke and started charging about the house room to room, and insisted on sitting on Junie's lap many times. 

16 mar - vacation time ! We did a one night staycation at the Capella and had a great time. Toby is off chasing peacocks. Things are really good... but the spectre of pancreatitis would haunt us again. 

WHAT WOULD WE HAVE DONE DIFFERENTLY

Acute pancreatitis can lead to chronic pancreatitis. What happened to Toby would be a precursor to things going wrong down the road. 

https://en.wikipedia.org/wiki/Pancreatitis 

Reduce the risk of pancreatitis as much as you can ie. No table scraps - day after thanksgiving in the US is not just black friday, but the day that vet clinics are busiest with pancreatitis cases! 

Avoid fatty foods. But, if you are keen to put your dog on a ketogenic diet (high fat diet to induce ketosis which helps starve out cancer) be sure to use the right type of oils / fat and organ meats, and NOT over-do it in one single helping (gradually change the diet), and make sure that your doggo is made to go on walks to burn off excess glucose. Occasional fasting will also help to bring about / maintain ketosis.  Remember - your doggo doesn’t need all that food. it’s really the cancer you end up feeding. 

[caninelymphoma-blog]

3. Time flies when you’re having fun... Not

12 Jan 2018 - higher dose of vincristine administered (meant to have started on 5 Jan). On the following 2 days, he couldn't eat much. In addition to the usual prednisone, Toby's been given immunity boosters and traditional chinese medicine that are meant to help him increase his red blood count and keep him in good shape. (see the link above for recommendations) Not sure if these things were helping, but he was energetic most of the time, with exception of day 2 and day 3 after chemo. He's usually a bit tired and sleeps more.

16 Jan - started on sweet apricot kernels (some studies purport that amygdalin in apricot kernels were potent cancer killers). Well, we tried for a little while but did not have much luck. We ground the kernels into powder and added it to his food. He didn't mind it but after weeks of doing this it wasn't clear if anything had changed. So we stopped.

19 Jan - week 8:  Vincristine again. 1 week break following that we were given more vitamin c shots. Again, i'm not sure if these helped at all. No noticeable reduction in lymph node size and it was truly a pain to see Toby walk around with a catheter in his paw. Further, Toby tended to feel pain when the Vitamin C went into his veins. Later on, while speaking to Animal Recovery Center @Serangoon Rd, we would learn that Dr. John Paul Lye had tried taking in Vitamin C intravenously to see what it would feel like so he could better understand what doggos had to go through. His conclusion? It hurts.

20-22 Jan Toby couldn't sleep much. He kept panting. Is he in pain or discomfort? We are not sure. Otherwise, he was in good spirit. His appetite is better now. (In hindsight now, we realize that it was the after effect of vincristine causing him a fever!)

7 Feb - Dr Travis at gentle oak (Dr Lee wasn't available) determined that Toby had an infection therefore doxorubicin cannot be done. Put him on IV injections of vitamin B and antibiotics.

11 Feb - went to see the vet again as Toby continues his sleepless nights. on the 13th, we decided to rub some Lavender oil seemed to help. He slept well after that. Lymph nodes still large ish but softer. (In hindsight again, he started sleeping well because the antibiotics were helping him fight off the infection. Clearly i'm now pissed off at Dr. Lee for not realizing that vincristine causes a fever when his immunity is weak and susceptible to infection)

“Back here again?? C’mon guys... Dis is not cool ”

So.. Time just flies. A month goes by and Toby isn't better. Each time at the vet, we arrive at the appointed time and STILL end up waiting about 30mins ~1.5 hours as Dr.Lee is super busy. So, Toby sits there on Junie's lap, shivering away in fear, stressed out because there are other animals suffering.

Because we didn't know better, and because we thought this was the best we could do for Toby, we suffered in silence. We spent that time speaking with other pet owners who were also waiting, and shared our experiences and trade stories. That was the one bright spot worth mentioning.

WHAT WOULD WE HAVE DONE DIFFERENTLY?

Clearly, having a vet that has more experience dealing with cancer and chemotherapy after-effects, and who is more invested in your pet and can spend more time with you, makes a world of difference. Work with a vet who really wants to/ has the time to help you. Ask around and try different vets.

I am no medical expert but i would AVOID Vitamin C injections. Our observation is that it only made Toby feel sick and had zero impact on fighting cancer. There is some research / studies in humans that show how IV vitamin C helps complement chemotherapy to keep cancer growth at bay, or to reduce side effects. It may work for your doggo, but it was useless in our opinion / useless for Toby.   A week's worth of high dosage IV Vitamin C cost us a fair bit as well. This wasn't a cheap option and certainly strikes me more as a nice to have.

Twice now, the CHOP protocol was delayed for a week each time, due to the infections / fevers that could have been prevented by pre-emptive antibiotics per my earlier post.  This needs to be avoided.

[caninelymphoma-blog]

2. Braver than any of us

1 Dec 2017 – we started Toby on chemotherapy with the O in CHOP: Oncovin® or Vincristine. Side Effects: Diarrhea. Panting. Restless nights. He was also on prednisone on a daily basis. The vincristine had a good, noticeable effect on the lymph nodes about 3 days later: All submandibular and popliteal lymph nodes shrunk from quail’s egg size to pea size.

We read up on the benefits of the budwig diet and decided to give it a go. the idea being that flaxseed oil, rich in Omega 3 Fatty acids, lignans and phyto estrogens, in combination with cottage cheese and other food restrictions, help fight cancer.

We tried it with Toby but failed. His appetite was already affected by the side effects of vincristine, and he hated the Budwig combination of cottage cheese + flax seed oil (we still have 2 big bottles of the best cold pressed extra virgin flaxseed oil in our fridge if anyone wants it…. ) He basically started getting put off by food with the budwig, because we kept trying to trick him into eating his usual food, wrapped around some cottage cheese and doused with flaxseed oil.

“Budwig diet ? Hell noooooo...  yuck”

We also subscribed to the raw diet and stopped giving him cooked chicken – one of his fave treats – and also his favorite dry kibble from TIMBERWOLF PLATINUM. This is actually a really good product, grain free, natural ingredients etc. When Toby was put on this initially years ago, his fur coat gain lustre, his energy levels improved and his stools became firm. He became healthier. But research shows that kibble can be carcinogenic and chockful of starch which increases the glycemic index (ie. spikes blood sugar). So we started feeding him mostly grass fed beef – dry freeze for minimum 3 days to rid it of bacteria, then sliced thin and he would usually eat it all without complaint. We did try to give him budwig for a whole week but it was really challenging to get any into him. He started putting up a fight and making a royal mess of himself. We did not resort to syringe / force feeding.

2 weeks after the vincristine, his lymph nodes were already growing back to quail’s egg size. We moved on to cyclophosphamide which had fewer side effects but we had to be very careful with handling the tablet and fed him orally with some meat wrapped around it, with gloves and also his poo. He went back to Gentle Oak every week to get his blood tested. He handled it like a champ. He was truly braver than any of us and still constantly played with us, and got excited at car rides and walkies. We would sometimes get really down realizing that Toby would leave us sooner than expected. He was really in the pink of health leading up to this. We’d feel so fearful of losing him and would cry sometimes just thinking about it. Cyclo had very little effect on shrinking the lymph nodes. We held hope that this was part of a protocol therefore the combo effect of Vin – Cyclo – Doxo would massively shrink Toby’s lymph nodes. We just needed to get to Doxorubicin. (scheduled on 5 Jan)

29 Dec – Toby started to cough when he barked at other dogs. It seemed like there was a chest infection of sorts affecting him. when he got held back by the leash, he would choke and cough due to the collar. So we switched to a harness.

“Harness !? Try harnessing up this beauty will ya!” 

5 Jan 2018 at Gentle Oak – Toby couldn’t proceed with scheduled doxo due to the cough that he caught. Basically his immunity is now worse, due to the cancer and the chemo (remember that Chemo kills rapidly-dividing-cells but also healthy cells) he became more susceptible to bacterial infections. Vitamin C injections were administered by Dr.Lee to fight off infection but lymph nodes kept growing. Note the Vitamin C injections had to be given to him through an IV catheter in his paw. This caused a bit of pain but prolonged discomfort because he had to walk and sleep with it. We also noted that his abdomen kept growing in size and he looked massively bloated. We did an ultrasound at Dr. Lee’s advice and can see that his spleen had become the size of a German shepherd and covered with spots / lesions. This is not a good sign – basically the spleen acts as the body’s biggest lymph node. Cancer 1, Doggo 0.

So.. Again we ask ourselves

WHAT WOULD WE HAVE DONE DIFFERENTLY ?

Instead of fretting over the anti-cancer / keto meals that he wouldn’t eat and giving in to him by reverting to his usual favourite meals, we ought to have let him go hungry ! Restricting his calories/Intermittent Fasting would in turn help his body expend all the glycogen reserves and encourage the metabolic switch from burning glucose to ketones.. which would be made possible thanks to

Changing his diet to be high in fat, low in carbs, low in protein… with lots of activity. For this you can mix fatty meats (beef, duck, salmon), organ meat, coconut oil, flaxseed oil, quail egg etc. Here’s an article about the benefits of a ketogenic diet 

Consider putting your doggo on preventive anti-biotics to keep infections at bay. This is rather controversial as gut bacteria gets wiped out and causes other type of problems, but supplementing your doggo’s diet with prebiotics and probiotics and a wide variety of food, will help mitigate issues. Most importantly, the huge advantage is that he would have been able to stick to the schedule / protocol to ensure he gets the best chance of kicking cancer’s ass into remission, instead of giving it time to adapt and evolve and develop further resistance.

[caninelymphoma-blog]

Read this first !

Our objective is really to share our journey so your doggo can benefit from this, and hopefully live a long and happy life.

When it all began in late 2017, we scoured the internet for all types of information about canine lymphoma and found various studies, podcasts and sources which proved useful. Most of it was from the U.S. and some were really dated. There is so much to read up on it can be overwhelming. One example would be this link which gives a rounded view of what to expect and the tendencies of dog breeds:  http://www.akcchf.org/canine-health/your-dogs-health/canine-lymphoma.html

I would actually prefer not to write this up and only focus on Toby’s awesome-ness in life. I do not want to remember the long vet consultations, the needles and the chemo, how Toby shook and cried whenever he realized that he was en route to the clinic (classic case of the thought bringing more pain than the act itself) and especially not the final 2 weeks where his health deteriorated so quickly – but I think this may help others. We shall provide detail on what we went through with him though it brings so much pain just ruminating about what could have been a better way to help Toby and extend his ‘healthspan’. Everything seems so straightforward in hindsight.

Our objective is to help others navigate this rollercoaster journey a little better than we did. We will start from the very beginning, but first, some key facts about our precious pupper, Toby.

Breed: Maltese x Shih-Tzu cross, from Melbourne Australia.

Date of birth: 2 Apr 2005

Diagnosis: Fine needle aspirate of submandibular lymph, canine lymphoma. Based on response to treatment it was most likely a very advanced B-cell. Did not perform biopsy for our preference to avoid inflicting pain/trauma

Age at time of diagnosis: 12 years and 7 months. Nov 2017

Age when Toby left us to go to doggy heaven: 14 years and 5 days. 7 Apr 2019

Lived with Canine Lyphoma for at least 1 year 5 months.

Weight*: ~8 kg at the start…

Sex: M, castrated at age of 1

Diet*: Boiled Chicken, Carrots, Tomatoes with dry kibble. Kibble brand: Hill’s Science Diet up till age of 7. Switched to Timberwolf Platinum thereafter.

Treats: Greenies, milk bones before the age of 11, deer sinew and healthier treats thereafter

Exercise / Activity: walked twice a day, usually for short periods ~5 mins or less. Taken on longer walks periodically to keep general fitness levels up.

Other pre-existing conditions: None, aside from usual minor issues ie. mild ear infection, occasional tick bites

Where: Lived in Melbourne for first 3.5 years, moved to Singapore for 3.5 years, in Tokyo, Japan for 3.5 years, then back in Singapore for the remainder of 3.5 years.

*Note that his diet and weight changed dramatically over the course of the treatment, as one would expect… we stopped feeding him kibble after doing all our research, among other changes we put Toby through…

[caninelymphoma-blog]

1. Heart in a woodchipper

 9th May 2019 

A quick word about Toby (before getting into his journey):

Toby is a fighter. He lived for 14 years, of which 1 year and 5 months was a battle with canine lymphoma. He went through various types of chemotherapy, a very strict diet with various boosters and supplements, hyperbaric oxygen therapy, and countless visits to the vet which he hates. Before lymphoma, Toby was the perfect picture of health. Everyone who met him thought he was at most 7 yrs old, when he was in fact 12. We had so many good laughs when children would call out to their mom or dad saying “Look at that puppy!” or “So cute… i want a puppy too”

He brought out the best in us through the 14 wonderful years he gave us. We love him so much and hope we’ll see him again someday in heaven.

Christmas 2017 – Toby is 12.5 yrs old and weighed ~8kg here and had the appetite and energy of a champion beardog!

“Raaaarrrr... I hate taking photos.. but i love you guys so i will put up with this.”

Nov 2017: Took Toby to the vet close by our place at Barkway Medical, due to eye discharge. The vet gave some eyedrops but noticed that Toby’s lymph nodes were swollen in both the submandibular (below the jaw, neck region) and popliteal (hind legs, behind the knees). Antibiotics prescribed. perhaps it was an infection. After a week, Toby’s lymph nodes continued to swell. Took him back for a blood test where lympocytes and neutrophils were off the charts. Doctor suggested that we check for canine lymphoma either by biopsy which means extracting an entire lymph node, or fine needle aspirate which is less invasive. We opted for FNA and hoped for the best. The test results confirmed that Toby was dealing with canine lymphoma.

At this point, it hit us really hard. Like our hearts were thrown into a woodchipper, shredded and spat out unceremoniously. Toby is a huge cornerstone of the life Junie and I built together and we love him like our own child. We reeled from the news and started googling the shit out of canine lymphoma. The prognosis for multicentric lymphoma (B-cell or T-cell) is very poor: 1~2 months if left untreated, ~6 months on average if prednisone (a type of inexpensive steroid with little side effects) is used, and on average 1 year ~14 months (for B-cell) using chemotherapy e.g. CHOP protocol (cyclophosphamide, doxorubicin, vincristine, prednisone). We were instantly thrown into a world of anguish, but wanted to believe that Toby, with help from his family, could fight this.

The doctor at Barkway tried to refer us elsewhere as they were not equipped to deal with dogs with cancer. He also mentioned that one of his staff was pregnant and for her safety would prefer if they did not have to handle cancer medication as some of it can be highly toxic. We started looking around for a vet who can help us. Natalie Prakash was mentioned by Barkway as the only certified canine oncologist in Singapore (Mt Pleasant) but the notoriety of that animal hospital made us look elsewhere. And so we began with Gentle Oak @Ghim Moh. Our friend had a good experience there for some other issue. We read the reviews and liked what we saw: holistic treatment of chemotherapy and alternative medicine. Dr.Lee in particular was more conservative on chemo dosage and advocated using other remedies. Having seen how cancer’s side effects had ravaged close friends and family and robbed them of quality of life, we decided to start with Dr. Lee.

Gentle Oak is extremely popular. Our first appointment there She started Toby on prednisone right away and scheduled Toby to come back a week later for his first dose of vincristine. We decided not to pursue finding out whether Toby’s lymphoma was B-cell or T-cell, and treated it as if it was B-cell. The reasoning behind this is, according to Dr.Lee, was that it wouldn’t make much difference in terms of the treatment. T-cell is the worst: the treatment barely works, and it’s very difficult to push it into remission; so just pray and hope that it’s B-cell which responds better to treatment and has longer remissions periods.

I will pause here .. this is the end of Chapter 1: how it first happened and how we reacted / steps we took. But… i’ve had a lot of time to reflect, and if i could turn back time I would do things differently. So, here goes.

WHAT WOULD WE HAVE DONE DIFFERENTLY?

Do not start with prednisone BEFORE Chemotherapy. Listen to this: http://www.radiopetlady.com/shows/podcast-pcv/lymphoma-importance-delaying-prednisone-chemo/   Basically the efficacy of the chemo in killing cancer cells is lowered due to prednisone. Prednisone (or prednisolone) should be given after chemotherapy begins. 

Realize that for fast spreading cancers like lymphoma it’s best that chemo is started rightaway alongside a change in diet. Dogs tolerate chemotherapy much better than human beings so fret not. Especially if your doggo is already in good shape to start off. I felt that we ought to have been aggressive with it instead of relying on alternative / holistic / natural remedies. This is not a drill. Get your act quickly and do not fear chemotherapy. In fact it’s the only thing that really beat cancer back. You will see in later chapters that we threw everything at it.

Go see Dr. Tham at Jireh Vet, Balestier. He has heaps of experience treating cancer patients, and has a much wider repertoire of treatment and a much more dynamic approach. You see, the thing about cancer is that it is constantly evolving and your dog’s immunity can be compromised in many ways that typical studies do not cover off, while undergoing chemotherapy. This causes lots of complications. Dr. Tham’s approach works because he spends a lot more time understanding each case – as opposed to super popular vets like Gentle Oak where your pet is one of the 50 patients they see therefore the likelihood of the vet fine-tuning the treatment to factor in what worked better and what didn’t for your doggo, is a lot lower. Dr. Tham isn’t running his vet to maximize profit. He’s truly interested in the better outcome.

Put your dog on a 24 hour fast with water from time to time. There’s excellent research and data around how fasting helps improve cell health and promote autophagy. it basically helps to starve off cancer cells (sensitizing cancer cells to death). The re-feeding after fasting helps activate stem cells and the regrowth of healthy cells.

Additional information on intermittent fasting and caloric restriction https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5783752/