Palliative Radiation

[Guest snakes]

Background, Boy grey diagnosed with OS in front leg back early Jan, limping is getting a little worse lately and the vet suggested palliative radiation in conjunction with pain meds to help.

 

Has anyone done or explored palliative radiation for thier pup/s?

Any experiences, good, bad or ugly would be appreciated. If anyone can give information about the cots involved too that would help.

Thanks so much.

[Guest Swifthounds]

Did you opt not to do amputation?

 

:grouphug

[RobinM]

I don't know if OSU site has the radiation stats alone. But here are the stats which under any circumstance suck.

 

 

Treatment and Prognosis

The treatment of choice for dogs with OSA is amputation (View "Bosha's" video) with adjuvant single-agent or combination chemotherapy. The median survival time in dogs with appendicular OSA treated with amputation alone is approximately 4 months, whereas in dogs treated with amputation and carboplatin, or amputation and doxorubicin it is approximately 1 year. As of now, survival and remission times in Greyhounds do not appear to be any different from those in other breeds. Amputation in Greyhounds with OSA frequently results in severe postoperative bleeding (24-48h post-surgery) around the surgical site, leading to subcutaneous blood accumulation in the other limbs, ventral thorax, and ventral abdomen; these dogs typically have normal hemostasis profiles (APTT, OSPT), and the severity of bleeding decreases after administration of fresh frozen plasma. Aminocaproic acid (AA - Amicar®) is a commercially available inhibitor of fibrinolysis (procoagulant) commonly used in humans with postoperative bleeding that can be administered IV or by mouth.

 

 

Administration of AA (500-1,000 mg PO q8h for 5 days starting the day of the surgery) prevented severe postoperative bleeding in Greyhounds undergoing surgery.

A novel surgical approach for dogs with distal radial osteosarcomas consists of sparing the affected limb. Instead of amputation, the affected bone is resected and an allograft from a cadaver is used to replace the neoplastic bone; novel biomaterials are also currently being investigated for this purpose. The dogs are also treated with intravenous carboplatin or doxorubicin and, in general, have almost normal limb function. The main complication is the development of osteomyelitis in the allograft; if that occurs, the limb frequently needs to be amputated. Survival times in dogs treated with limb-sparing procedures are comparable to those in those that undergo amputation plus chemotherapy, with the added benefit to the owners of having a four legged pet.

 

The dosages and the recommended ways of administering chemotherapy for dogs with OSA are given in Table 1. At our hospital, we use either of the drugs mentioned above immediately after amputation, and for a total of 4 to 5 treatments. The cost of carboplatin chemotherapy is quite high, approximately, $7.50/kg of body weight/dose and in the case of the doxorubicin reaches almost $2/kg of body weight/dose.

 

We are currently investigating a novel approach to modulation of chemotherapy in Greyhounds with OSA, by administering suramin, a polysulfonated naphthylurea that, at low doses, has been shown to increase sensitivity to doxorubicin in in vitro and laboratory animal models of cancer, by inhibiting binding of fibroblast growth factor (FGF) to its receptors. Preliminary results are encouraging, and the administration of suramin prior to doxorubicin does not appear to potentiate the toxicity of the chemotherapeutic agent.

 

Limb amputation alone results in typical survival times of 3-4 months. Postoperative adjuvant chemotherapy prolongs survival times to 12-18 months in most dogs. As of now, it appears that survival times in Greyhounds treated by amputation and conventional chemotherapy are somewhat shorter (8-12 months).

 

If owners are reluctant to allow the veterinarian to amputate the limb, local radiotherapy plus carboplatin may be of some benefit. However, in our limited experience, most dogs are eventually euthanized within 3 to 4 months of the initial diagnosis because of the development of pathological fractures (i.e., after radiotherapy the tumor is not as painful; therefore the dog regains normal use of the limb and fractures the area), osteomyelitis, or metastatic lesions.

 

Zinger

 

Pain control is essential in dogs where surgery is not an option; we have used either NSAIDs (carprofen, deracoxib, meloxicam) at recommended doses, or bisphosphonates such as alendronate (Fosamax®), at a dose of 10 mg/dog once a day or pamidronate (Aredia®), at a dose of 1 mg/kg, IV as a 30-minute CRI, every 3 to 6 weeks. Drugs such as tramadol (Ultram) at dosages of 1-2 mg/kg, PO, q8-12h may also be beneficial.

 

Chemotherapy may modify the biologic behavior of the tumor, resulting in a higher prevalence of bone metastases and a lower prevalence of pulmonary metastases. Moreover, the doubling time (i.e., growth rate) of metastatic lesions appears to be longer than that in dogs that have not received chemotherapy, and there appear to be fewer metastatic nodules in treated than in untreated dogs. Therefore, surgical removal of the metastatic nodules (i.e., metastasectomy) followed by additional carboplatin or doxorubicin therapy may be recommended for a dog that has been treated with chemotherapy after amputation of the limb and in which one to three pulmonary metastatic lesions are detected.

 

 

Chemotherapy Protocols for Greyhounds with Osteosarcoma

1. Carboplatin (Paraplatin^®): 300 mg/m2, IV, q3-4 weeks or
2. Doxorubicin (Adriamycin^®): 30 mg/m2, IV, every 2 weeks, for 5 doses

 

 

 

 

 

[NeylasMom]

Background, Boy grey diagnosed with OS in front leg back early Jan, limping is getting a little worse lately and the vet suggested palliative radiation in conjunction with pain meds to help.

 

Has anyone done or explored palliative radiation for thier pup/s?

Any experiences, good, bad or ugly would be appreciated. If anyone can give information about the cots involved too that would help.

Thanks so much.

Sorry to hear that things are progressing with your boy.

 

When Neyla started to show signs of increasing pain, I considered 2 palliative options in addition to the medication she was getting, one was radiation and the other was IV pamidronate. I do think that both of these options will provide better quality pain relief and for longer periods of time if they work than increasing pain meds alone can do.

 

For us, costs of both treatments were similar, ~$600 per treatment although if I had opted for radiation it would have been covered separately under my pet insurance, which would have saved me money (there's the general cancer reimbursement with VPI but they reimburse additionally/separately for chemo and radiation treatments). Cost would have also ended up being different due to timing, pamidronate generally done every 4 weeks ongoing, radiation given twice in 2 days and then you're done, but we never did more than one treatment.

 

According to my oncologist, both could take about an equal amount of time to show an effect (3 weeks) and both could provide about the same amount of additional quality of life (2 more months) according to studies although I saw results from the pamidronate immediately and have heard similar reports from others. The other similar issue that you need to consider is what the tumor progression looks like on x-ray. If the bone has really deteriorated and is at risk of fracture, you do need to consider whether you are prepared for that happening and what your decision will be if it does. The danger is that with the additional pain relief, your dog is more likely to be more active and do something that can cause a fracture. Of course some dogs fracture their leg just taking a step so it's all something of a crapshoot, but you do have to think about it. I decided I would not pursue those treatments if the bone had deteriorated too much because I wanted to let Neyla go at home and wouldn't risk having her fracture the leg and having to be rushed to the e-vet in pain and put down there.

 

As far as teh actual treatments, obviously I can't give you much more insight into the radiation. I have 2 friends who did it with their dogs, one whose dog deteriorated quickly afterward and had to be let go, and another who saw some benefit but decided to amputate afterward anyway. If you check out the bone cancer yahoo group, there are a good number of people who have done it and could give you feedback, but I noticed that many chose to do the radiation and pamidronate together so they may not be able to tell you whether it was one or the other that worked.

 

For me, I chose the pamidronate for a couple of reasons. One was that I was not comfortable anesthetizing Neyla at all, let alone 2 days in a row because she had had a poor reaction to anesthesia in the past and also because as Dr. Radcliffe put it, it's a "little bit of death" each time you use it. I also favored the pamidronate because early research shows that it may actually help to rebuild bone density, and also may have anti-cancer properties. So basically I thought I was getting more bang for my buck so to speak.

 

There is a risk of kidney damage from the pamidronate. We did see that, but we also believe in retrospect that Neyla had damaged kidneys going in and she probably wasn't a good candidate for that reason. With radiation, the only risk is the risk of anesthesia.

 

Personally, I think either are good options to try if you're comfortable with the low risks involved and you aren't worried about bone fracture. If you do choose radiation, make sure the vet is up to speed on the newest protocol, which is 2 days in a row, not once a week for 4 weeks. At least that knocks the number of treatments in half.

 

I hope that helps. Sending good thoughts for your boy.

[Guest snakes]

Sorry, forgot to mention we are not doing amp. I weighed the options of survival time vs costs and his past health (seizures, mast cell tumor on hind leg, arthritic toe) and decided it wasn't for us. So i am going the palliative/supportive/homeopathic route. He has been doing well on gabapentin and tramadol (didn't tolerate novox, holding off on deramaxx till we need it).

 

If i could have done amp without chemo and radiation then maybe i would have done it, but i personally can't put him through all of that.

 

Trust me i have researched a lot on survival times, chemo, meds and amp.

 

Hence looking into palliative radiation, any experiences welcome.

 

 

p.s.- Neylas mom, thank you for your reply and I agree totally wiht factoring in risk of fracture, that is something i absolutely don't want to happen for both his benefit and my experiences/memories.

Edited March 27, 2011 by snakes

[NeylasMom]

Oh, one more thing - not sure if you've already read this article as it's included in the first page of the osteo thread and I know you've been in there, but it's a nice overview of pain management for osteosarcoma in dogs and specifically palliative radiation.

 

Also, I found a lot of good research articles on IV pamidronate on pubmed and would imagine you can find a good number on radiation as well if you are like me and want to read everything you can possibly can. The articles on pamidronate nicely outlined the risks, the likelihood it would work, and also the evidence that suggests anti-cancer and bone density building properties. Just took a quick look - putting in this search term: "palliative radiation canine osteosarcoma" pulls up some promising articles. Also, once you click on an abstract link, there's a section on the right that lists "Related citations" and will often lead you to more relevant articles.

 

I hope that helps.

[sweetdogs]

I used radiation for my bridge girl Liath whose tumor was high up on her shoulder near her spine. Surgeons would have amputated but she was terrified at the vets & frankly, I just don't like the percentages for amp yet. She was 11 at the time. She needed an MRI first to pinpoint exactly where the tumor was & then had 6 treatments. I think the total cost was $3,000 (back in 2007, 2008). She did so well with it all - I was really impressed. She didn't freak out & it definitely did shrink the tumor. She was on metacam, tramadol & gabapentin. I tried artemisinin but she would stop eating after every dose. I also tried pamidronate - the first treatment went very well but she had a bad day for the second & it was stopped in the middle.

 

I do believe it bought us some time & I can't say anything bad about the whole procedure. It took a while to get things put in place - waiting for doctor appts, a radiologist to read the MRI, finally getting the first treatment - that part was very frustrating since time was of the essence, IMO. I let her go when she had some sort of "event", maybe threw a clot, & was loosing her back end. That left her with only one good leg & I decided that was enough. She was such trooper - I was so proud of all she endured.

 

Best wishes for you & your boy.

[Guest Swifthounds]

If i could have done amp without chemo and radiation then maybe i would have done it, but i personally can't put him through all of that.

 

Was there a reason (medically or otherwise) that amp w/o chemo/radiation isn't/wasn't an option?

[Guest snakes]

If i could have done amp without chemo and radiation then maybe i would have done it, but i personally can't put him through all of that.

 

Was there a reason (medically or otherwise) that amp w/o chemo/radiation isn't/wasn't an option?

 

Noone would proceed, (and i basically got a blasting email from OSU about it BTW whom i don't converse with anymore) because they said it would be too major a surgery to only do the amp and not the then do the radiation and chemo. One opinion given was that since he had the mast cell tumor on his back leg it wasn't worth it anyway since that would take him if the osteo didn't.

I also don't know if it would work out well since i live up two flights of stairs and he is heavy

[tbhounds]

Why radiation?? Usually, the amp is followed by 5 rounds of chemo.

[JJNg]

Noone would proceed, (and i basically got a blasting email from OSU about it BTW whom i don't converse with anymore) because they said it would be too major a surgery to only do the amp and not the then do the radiation and chemo. One opinion given was that since he had the mast cell tumor on his back leg it wasn't worth it anyway since that would take him if the osteo didn't.

I'm a bit surprised by this. As a general practitioner, I'm still advising that even amputation alone is a good option to consider. Are the specialists changing their thoughts on this? Has anyone else had this experience with OSU - pushing the client to do adjunctive therapy and advising against amputation alone? Or did your boy's mast cell tumor weigh into this recommendation for him?

 

If the dog is a good candidate for amputation, that completely takes away the pain. Even if the survival time and eventual outcome is not changed, once the immediate post-op pain is over, you no longer have to manage pain for the rest of the time the dog has left. However, I've also known of a couple dogs that lived a year, and even 2 pain free years after amputation alone.

[Guest Swifthounds]

Noone would proceed, (and i basically got a blasting email from OSU about it BTW whom i don't converse with anymore) because they said it would be too major a surgery to only do the amp and not the then do the radiation and chemo. One opinion given was that since he had the mast cell tumor on his back leg it wasn't worth it anyway since that would take him if the osteo didn't.

I'm a bit surprised by this. As a general practitioner, I'm still advising that even amputation alone is a good option to consider. Are the specialists changing their thoughts on this? Has anyone else had this experience with OSU - pushing the client to do adjunctive therapy and advising against amputation alone? Or did your boy's mast cell tumor weigh into this recommendation for him?

 

If the dog is a good candidate for amputation, that completely takes away the pain. Even if the survival time and eventual outcome is not changed, once the immediate post-op pain is over, you no longer have to manage pain for the rest of the time the dog has left. However, I've also known of a couple dogs that lived a year, and even 2 pain free years after amputation alone.

 

I would like to know this answer as well.

[GeorgeofNE]

I think some of you are missing the part where the OP cited COST, age, and other health issues as reasons for not amputating.

 

 

 

As to "waiting on Deramaxx until it's needed," if Tramadol isn't doing it, then I assure you Deramaxx won't. Deramaxx is just a NSAID. If you're past the point where Tramadol is working, I doubt an NSAID is going to do much.

[BootsyCollins]

For what it's worth, when Argos was diagnosed with osteo in his front leg, we opted against amputation as well. I consulted with Ohio State during this, and I got a very kind email from one of the members of Dr. Couto's team saying he agreed with my decision.

 

My point is, you don't have to explain to anyone on here or anywhere else why you chose not to amputate. I hope you're able to keep your boy pain free for a bit more time.

[Batmom]

My point is, you don't have to explain to anyone on here or anywhere else why you chose not to amputate. I hope you're able to keep your boy pain free for a bit more time.

 

All of the above. And some more hugs for you and your sweet pupper.

[Guest snakes]

I knwo people are curious and don't mean anything by asking for reasons for not amputating, they mean the best and want the best for everyone.

I was told that amp with chemo and possibly radiation (i didn't pursue to get details) would be at least 6-7k, that was a major factor for a supposed survival time of not much more than just palliative care.

Although i told OSU about the mast cell tumor, they declined to say whether they thoguht he was an amp candidate (fair enough, I understand that since i am not 'officially a client'). This was part of thier reply:

 

"We do not do amputation without postoperative chemo or radiation. Limb amputation alone results in typical survival times of 3-4 months, and amputation is a major and expensive surgery that the patient and owner go through."

 

We are actually almost (1 week away) from 3mo survival presently

We have a oncology consult next tuesday to explore options at this point, including palliative radiation.

 

I was trying the deramxx just to see what combination worked best, i still had some room to go up in the tramadol and the gabapentin, however fedX is very susceptible to hyperanalgesia. So far gabapentin has tbeen teh wodner drug for us and I will most liekly increase that if needed soon.

 

Thank you for all your input and support. Especially Neylasmom and Sweetdogs for thier information.

[sweetdogs]

I was trying the deramxx just to see what combination worked best, i still had some room to go up in the tramadol and the gabapentin, however fedX is very susceptible to hyperanalgesia. So far gabapentin has tbeen teh wodner drug for us and I will most liekly increase that if needed soon.

 

You might feel a little leery about it, but did you ask OSU about the hyperanalgesia? It's certainly common that greyhounds have weird drug reactions. Maybe they might have some thoughts on this for you.

 

 

[Guest d0ggiem0mma]

OSU does not do amputation w/o chemo because the survival time for amputation alone is only 3-4 months... and it takes several weeks fully recover from surgery. With chemo, the median survival time is 1 year and many dogs live even longer than that.

 

jjng- There's really no point in amputation if you don't do the chemo. If the clients do not want to do the chemo (OSU provides the drugs for free and they can be shipped to and given by the regular vet) they are probably better off doing radiation and hospice care. Survival time for radiation & pain management is 3-4 months, just like the amputation but there is no major surgery to recover from.

[Jiffer]

I don't blame you for choosing not to amp.

 

I have no experience with providing palliative radiation, however, but wanted to express my understanding and support.

 

As with any of these procedures, I'd just make sure you know 100% what the potential side effects are so you can be prepared and completely informed on the treatment.

[Guest Swifthounds]

OSU does not do amputation w/o chemo because the survival time for amputation alone is only 3-4 months... and it takes several weeks fully recover from surgery. With chemo, the median survival time is 1 year and many dogs live even longer than that.

 

jjng- There's really no point in amputation if you don't do the chemo. If the clients do not want to do the chemo (OSU provides the drugs for free and they can be shipped to and given by the regular vet) they are probably better off doing radiation and hospice care. Survival time for radiation & pain management is 3-4 months, just like the amputation but there is no major surgery to recover from.

 

I really don't understand how there could be no point in doing an amputation absent chemo. All of the options that don't involve chemo (amp alone, administration of pain meds, radiation, etc.) are pain management options vs. primarily life extending treatments. Some people can't or choose not to do chemo either for $$ or personal reasons. The amputation can be pricey depending on the surgeon (I get the impression from what those who have done it through OSU that it's costly there, but it isn't necessarily that costly everywhere) but so can OSU's "free" chemo when you have to co-ordinate it through your regular vet.

 

The amputation, even if it won't be likley to provide longevity (though it can), does immediately rid the dog of the source of the pain if the cancer hasn't yet metastacized. Yes, there are weeks of recovery on pain meds, but that's weighed against weeks on pain meds with the pain source intact.

 

Except in the rarest of cases, we're not talking about hounds surviving more than a year or so post diagnosis in any case. Not that there aren't instances where they survive in remission longer than that or at least long enough to succumb to something else, but those are few and far between. No matter the course of treatment, we're only ever talking about extending the life of the dog briefly. Shouldn't the pain management be more important?

 

To the OP, I hope you get some useful perspectives from those who have gone the route you are considering. I was actually surprised that more people haven't chimed in to say they have done it. There are many different avenues, and many different opinions. Only you know what works for you and your hound. Hope you find the perspective you seek.

 

A to you and your hound.

[Guest d0ggiem0mma]

Let me just say that I don't disagree with the OP's decision to not amputate. That's one call everyone needs to make for themselves and for their own dog.

 

Swifthounds- I see what you're saying, especially about cost issues, but I think you misunderstood what I was trying to say. It's not all about extending life, that part you have right on. It's about preserving quality of life for whatever time they have. I do not personally feel it is a good idea to put a dog through an amputation for the HOPES of having them around for 3-4 months. They spend the first 2 weeks in a lot of pain even with medication. After that they have to re-learn how to walk, etc. etc. If it takes them 2 months to recover from surgery and they are only expected to live 3-4 months... what kind of life is that? By the time they recover from the surgery, they feel sick from the mets. I would think other pain management options would work faster and give better quality of life for a longer period.

[Guest Swifthounds]

I see what you're saying. I do agree that amputation can be quite painful, but I have never seen an instance (human or canine) where the pain could truly be controlled where the situs of the cancer was still present, through any means other than IV pain mess that make the patient nearly unconscious. I think we often mistake pain tolerance for the absence of pain. Bone cancers are about as painful as it gets.

 

I don't second guess anyone else's choices, I just question the wisdom of a provider limiting the way those options can be utilized.

[RobinM]

We did amp and chemo on a very active and "young" 9 3/4 aged girl. We got one day short of 5 months.

 

The recovery from the surgery was 3 weeks = 21 days

 

We lost at least 5 days for each of the 5 chemos. = 25 days.

 

 

total days lost- 46

 

Total amount of days we had her from initial diagnosis/amp (same time) 146 days.

 

3.4 months with amp and chemo- days when she was fine and happy.

 

Tough decision.

 

However, our girl fractured her leg. We felt we had no choice. We knew she wasn't ready to say goodbye yet. She did let us know when she was ready.

Edited March 28, 2011 by RobinM

[NeylasMom]

As to "waiting on Deramaxx until it's needed," if Tramadol isn't doing it, then I assure you Deramaxx won't. Deramaxx is just a NSAID. If you're past the point where Tramadol is working, I doubt an NSAID is going to do much.

Just an aside, this is not necessarily true - it's going to be different for every dog. Bone cancer pain involves multiple sources of pain including neurological (hence the Gabapentin) and inflammation (hence the NSAIDs). For us, the Deramaxx was actually most effective, especially earlier on.

 

I see what you're saying. I do agree that amputation can be quite painful, but I have never seen an instance (human or canine) where the pain could truly be controlled where the situs of the cancer was still present, through any means other than IV pain mess that make the patient nearly unconscious. I think we often mistake pain tolerance for the absence of pain. Bone cancers are about as painful as it gets.

 

I don't second guess anyone else's choices, I just question the wisdom of a provider limiting the way those options can be utilized.

Much of it does depend on where the dog is in their progression when diagnosed. For Neyla, she was running at top speeds in our condo, playing with toys, taking walks, basically a normal, happy dog aside from a few isolated days for 5 months. That was on the lowest dose of Deramaxx and Tramadol. But, I had no way of knowing we would get that much quality time. The next 2 months were more difficult and in retrospect, there were times when I wish I had been more prepared or more aggressive with pain management (we're talking about hours or parts of days, but even that amount of time seeing your dog in pain is too much), but for Neyla, not amputating was a good choice. I do agree with your bolded statement and I do as a result of learning that from my own experiences try to encourage people to be prepared with instructions from the vet and to be aggressive if necessary to manage pain, but in the end, each dog really is different and ultimately, I think so much depends on when the osteo is caught. Unfortunately it's very difficult to identify where you are in the progression except when the dog is clearly showing signs of obvious pain. Not an easy thing to deal with all around - my basic point being, I get where you're coming from, but sometimes good pain management can be achieved with early diagnosis and a selfless decision to let the pup go earlier rather than later.

[joejoesmom]

 

I don't second guess anyone else's choices, I just question the wisdom of a provider limiting the way those options can be utilized.

 

I just wanted to pipe in and say that OSU does not say that amputation without chemo would not be allowed at OSU. I have no doubt that they have said to some patients that they wouldn't do the surgery.. But I personally have heard them say that amputation without chemo can be done at OSU as long as the owner understands that this is not likely to extend the life of their dog much (just any additional time that they didn't have to be PTS because of the pain of osteo in the bone). They strongly recommend following amp with chemo as it typically quadruples the time the dog is alive with an enjoyable life. However, there may be instances that chemo is not possible due to the health of the dog. If the owner wants to try amputation without chemo, OSU would likely do the surgery, especially since there is a very slight chance that removal of the limb could be curative. If the dog has lung mets and chemo is not an option, I would suspect that they would decline to do the surgery.

 

Personally, having a dog who has been through amputation, I don't think I would do the amputation if chemo was not an option. The recovery was bad enough and long enough that I wouldn't do it to him for an average of 3 months life. This means that half the dogs make it less than 3 months. I personally don't think these odds are good enough that it would right for my dog.

 

Now that I have thoroughly highjacked the OPs thread:

 

I am so sorry that you have to deal with this horrible disease. Only you can make the decision for your dog. You obviously love him very much. I do not have any personal experience with radiation. I have had a friend tell me that it really helped the pain in her girl. But this is just one experience. I have no others to relate. I can, however, offer you a big hug and many prayers for you and your boy in the days, weeks and hopefully months ahead.

 

Jane