Looks Like Brain Metastasis

[TwiggysMom]

This is really long, and fairly specific to those with significant familiarity to brain tumors/seizures and their causes, so feel free to skip over.

 

Twiggy has been having what I believe to be focal seizures. I can’t remember exactly when they first started, but I think it was around the time she was diagnosed with osteo. The behavior was innocuous enough at first that it was easy to write it off as “quirkiness”.

 

It presents as “air licking” (licking out the front and sides of her mouth, and over her nose, but not *at* anything), combined with a quick head bob and an eye blink. Here is video. She is standing for this one, but she also has them while laying down.

 

She is somewhat responsive during them, i.e., she can move her head, take a few steps, etc., but she can’t seem to stop.

 

Maybe six weeks or so ago, I started wondering whether this was anything, but again it was still relatively infrequent (by that time maybe 1-2x/day) and didn’t seem alarming enough to bother mentioning (especially as I worry about every little balance check, pause before going upstairs, yipe, etc.). Also, it is difficult to distinguish this from more normal behavior unless I am looking directly at her, as she has taken to persistently licking her remaining front paw/wrist since the surgery (likely from excess use).

 

They have been increasing in frequency, and sometimes occur off and on all night (between 3 and 10+ per night). Sometimes it will stop and then restart less than a minute later. They occur primarily at night and in the very early morning hours.

 

I’ve tried to research this online, and also spoke to Twiggy’s oncologist. Twiggy turned 7 in October, and as such is out of the range usually considered for idiopathic epilepsy. This means that the seizures are almost certainly caused by disease. The main usual suspects seem to be brain tumor and head trauma. There was a good article here: neuro.vetmed.edu/neuro/seizures/seizures.htm (see? I’m learning to document my sources!) that indicated something I hadn’t seen elsewhere (although maybe other sources meant this but just said it differently). It indicated that seizures can be triggered by a lowered immune system. Would that make it possible that this is a result of (or exacerbated by) her chemo? I think the article might simply mean that puppies’ and older dogs’ immune systems are inherently weaker, and that is why non-idiopathic seizures are the norm in those age ranges.

 

Twiggy’s oncologist supported what I fear the most – that it is most likely a brain tumor. I’ve scheduled a neurology consult for Monday morning, and he may want to do an MRI (oy, $$$). The neurologist is board certified and was previously a full professor and the Director of the Comparative Neurology Service at OSU, so he likely knows Dr. Couto, which is a plus.

 

OK, I have a million questions: (mostly assuming that it is a brain tumor - any input you may have on any of these is greatly appreciated)

 

Would doing the MRI make a difference in prognosis or treatment?

 

I don’t know how I can put her through brain surgery (given her osteo/amp/chemo), but I don’t know how I can not put her through brain surgery, either. I am afraid of the focal seizures progressing to generalized seizures (which it appears they frequently do). Obviously, I couldn’t even consider brain surgery without doing a MRI first, but is that the main reason to do one?

 

Because I *think* the timeline of these started around the time of the osteo diagnosis (which we all believe was very early), is there much chance that this is a separate primary tumor not osteo-related?

 

Should we discontinue the carboplatin she is receiving for her osteo, since it isn’t effective in controlling brain tumors? She is scheduled for her 5th carbo treatment next Friday, and we were going to do a re-staging (x-rays, possible ultrasound),

 

Does the increasing frequency support the idea that they are caused by a growing brain tumor? (I know that repeated seizures do tend to reinforce additional seizures).

 

Multiple sources have stated that more than 3 seizures in a day are cause for emergency veterinary care. Does this include focal seizures?

 

Would it make sense to medicate to try to eliminate the seizures?

 

Any other questions I should have but haven’t thought of yet? I’m pretty much a wreck right now. I wasn’t expecting this particular path through osteo.

 

In the meantime, she is still her super-happy, energetic self. Half the time you don’t even realize there’s anything wrong with her at all, despite the fact that she’s only got 3 legs. So, as far as that goes, I’m still enjoying and having fun with her every moment I can.

 

I really want her to play for another summer. She deserves another summer, ‘cuz this one stunk.

[KF_in_Georgia]

Good lord, Wendy. This is so crazy, and you and Twiggy deserve an easier course through this cancer maze.

 

My only input--aside from a suggestion that your oncologist get in touch with OSU right away--when they talk about 3 seizures a day being cause for emergency vet care, I think they mean the more typical grand mal-type seizure. Start taking Twiggy's temperature frequently: get readings when she's not having seizures, when she is having them, after she's had them. When vets worry about dogs having repeat seizures, I think it's often because a dog's temp will climb dangerously high with seizures, so they want the dog getting drugs to stop the seizures before there's damage from the high temps. If Twiggy's temp is going up with the seizures, you may need to consider the ER when she's having a series of seizures.

 

Good luck to you and Twiggy.

[joejoesmom]

I'm sorry I don't have any answers for you. I assume that you have already contacted OSU or that your vet has/will. I just wanted to say how sorry I am to hear that Twiggy is having problems. Feel free to call me if you want to talk.

 

Jane

[TheFullHouse]

Gosh, I'm so sorry. I lost my Emmy to a brain tumor but it was not connected in any way to osteo. She was 10 at the time and we chose not to treat it because the tumor had already taken her sight and she had started having seizures. I hope you can find the answers to your questions.

[Batmom]

100% sure she doesn't have any mouth sores or similar?

 

Sending lots of hugs and best wishes for you and your lovely girl.

[greysmom]

Oh Wendy! I'm so sorry for you and Twiggy! No help, just lots and lots of good thoughts!

[MaryJane]

You brought up a good point about the chemo and the focal seizures - you might want to check with the neurologist whether the chemo may have made the seizures worse so that you are now noticing them. It could also be that she has been having them for awhile but, they were not obvious. I know Lucy's neurologist mentioned that toxic substances can trigger the seizures.

 

With Lucy I had been planning to do a MRI before starting seizure medicine but, as it turned out, I decided that the test was not "crucial" at the stage that she was at and that it would be better to wait until we reached a point where it was a "critical need for diagnosis". As a note, Lucy was 4 1/2 years old when the seizures started so she was in the age range when a brain tumor was less likely. We could start her on medicine without the MRI and that's what we ended up doing.

[BauersMom]

This really sucks. I'm sorry you're dealing with this.

 

I guess if I were in your shoes, I would probably do the MRI. For me, I would probably want confirmation if it was a brain tumor or "something else" - it may change how to continue with chemo, or if you continue with the carboplatin, etc.

 

But it's a tough decision, I know.

 

Please keep us posted.

[45MPHK9]

[JJNg]

100% sure she doesn't have any mouth sores or similar?

The video was a little dark, and it's a little hard to tell without seeing it in person, but I was wondering the same thing. While certain traits that you describe (head bob, inability to stop) seems to indicate seizure activity, I've seen dogs with mouth problems "air lick" like Twiggy appears to be doing in the video. I've seen it when there's a loose or damaged incisor, something stuck between the teeth, or sores or ulcers in the mouth. I would definitely recommend a very thorough oral exam.

 

I would also definitely do an OSU consultation, unless you think the neurologist may consult directly with Dr. Couto. This obviously isn't a typical manifestation of osteosarcoma metastasis, so I'd be interested in seeing if Dr. Couto has ever seen anything like this, or if he thinks it may be totally unrelated. Especially with the timeline of the episodes possibly starting around the same time as the osteo diagnosis, I would think that metastasis from the osteo would be very unusual.

 

Assuming this behavior really is focal seizure activity, having the MRI done may help make the determination of whether it is related to osteosarcoma. If it is brain metastasis, there may be multiple lesions. If it's unrelated, MRI may show whether it's a single, accessible brain tumor that could be surgically removed. If the MRI is normal, it's still possible that this is idiopathic epilepsy. While 7 is on the older side for this to manifest, it's still possible.

 

Increasing frequency of seizures does not necessarily mean a growing brain tumor. Seizures from epilepsy tend to increase in frequency with time too. If the episodes are confirmed to be seizures, you would definitely want to start her on anticonvulsant therapy. Even if it ends up being a tumor that can be surgically removed, you still have to manage the seizures for now.

 

Sorry you're having to deal with this additional complication. Sending good thoughts to you and beautiful Twiggy.

[tbhounds]

Personally, I would schedule the MRI if the neuro Dr suggests it. Having the MRI wll give you the answers you need to design the proper treatment plan.

Isn't her 5th and final carbo treatment coming up??

Really would be a greyt idea to send your questions to Dr Couto. I'm sure he'll steer you in the right direction.

Hugs to one of my fav GT hounds.

Edited December 10, 2011 by tbhounds

[TwiggysMom]

Thank you to everyone who made it through my long and disorganized post, and for all of your support and well wishes.

 

Kathy, I appreciate the information about temperature and seizures. Fortunately, that does not seem to be an issue with what Twiggy goes through. While I haven’t taken her temp, she doesn’t show any sign of elevated temperature, and her ears, nose, etc. all seem normal during and after episodes (even multiple ones). I'll be sure to keep an eye out for that (and move her thermometer to the bedroom!)

 

Jane, I haven’t contacted OSU yet (I know how busy they are!). I hope that the neurologist is willing to consult with Dr. Couto, since he was a significant member of the OSU veterinary program 10-ish years ago. Twiggy’s oncologist has made some not-so-great comments about Dr. Couto, so she is very unlikely to consult with him.

 

Batmom & Jennifer: I brush Twiggy’s teeth every day, and haven’t noticed any sensitivity or seen any lesions/sores, etc. (She comes running when I say “Time for Toofers!”) I couldn’t completely rule this out; but this is a very distinct behavior which is differentiated from 8 other specific licking-related behaviors she exhibits (all of which are normal; I can define them for you, but I’m already pretty long-winded ), and 2 other licking behaviors which she has never exhibited herself (nervous/submissive and prey-related). She is not in control of this activity, and while she can continue some other behaviors, it is clearly difficult for her to do so during an episode. Additionally, the episodes occur almost exclusively at night and in the dark. We stayed downstairs with all the lights on for two straight nights in the hope that I could get better video, and she only had 2 or 3 very short episodes each of those nights. One other thing: she does have a couple infections (yeast & demodex) on/near her nose, but those are only 12 days old (guessing, noticed the very beginnings 10 days ago, and b/c the daily toothbrushing, I’m pretty sure I noticed them early). All of that coupled with the increasing duration/frequency really seem to point to focal seizure (I think).

 

Jennifer & MaryJane (not sure if that’s your actual name!), I appreciate the ideas that this could still be idiopathic or a result of lowered immune system. Even though the episodes started before the chemo, wouldn’t the osteo itself tax the immune system? Also, when Twiggy was hospitalized for her amp-site infection, they gave her Acepromazine, I read that this drug can cause or exacerbate seizures. I only learned about them giving this from the invoice – they never consulted me about it; I would have told them to not give her ACE. Guess I’ll have to make sure they don’t give it again if I go ahead with the MRI (which I’m leaning toward doing after all the good input here).

 

TBHounds (I’m so sorry I don’t know your name), Twiggy’s 5th chemo is scheduled for next Friday. She is slated to receive 6 treatments total, but I don’t know whether it makes sense to do either 5 or 6 if she has metastasis in her brain since it wouldn’t slow that down.

[Guest Greyt_dog_lover]

Wow, I am so sorry you are going through this. Remember the good times this summer, I know of at least two, and I am sure there are a lot more. When Twiggy was running like the wind on three legs at GPA WI and GO this year. I am sure it is hard to see anything but what is going on right now, but don't forget the fun times you had this year. Not to mention how much she inspired everyone at both reunions. You and her have a lot of strength, never forget that.

 

Chad

[seeh2o]

No advice, just sending good thoughts and

[GreytHurleyDawg]

Oh, Twiggy and Wendy!! I am so sad to hear that Twiggy is exhibiting symptoms that could be related to a brain tumor. I REALLY hope it is nothing to worry about. Are these types of seizures very typical of a tumor? I reread your post and apparently the oncologist thinks so but I would hold out for the neurologist's input. Obviously, you are choosing the right path by ruling out the worst first....and I pray that it does get ruled out! Twiggy does need to see next summer and I want to see and meet sweet Twiggy myself.

 

I keep telling myself not to relax and trust that the chemo will do everything needed in my Hurley's case but it is so hard not to. Just keep fighting and don't give up. But if the time has come to make a big decision, then let me know how I can help because this is just too huge to believe. You are not alone in this!

 

I agree that Dr Cuoto and/or OSU can help. And they seem very nice and caring too.

 

Keep us posted, I am very hopeful that this could be drug-related or mouth-related!!!! Or who knows what else?

 

Johanna

[jamngrey]

No advice but wanted to send well wishes for you and your precious babe

[Charlies_Dad]

No advice/suggestions but know that you and Twiggy are in our thoughts. We really hope it's not a brain tumour. Myself I would go with the MRI even though they are expensive as I would want to know what is going on in there.

[robinw]

Wendy, is Twiggy on a fentanyl patch? Loca had similar symptoms. Turned out her fentanyl patch was placed inside her thigh instead of outside and she was having an overdose reaction. There was a lot more going on than that, but the evet said those particular symptoms were due to the patch.

 

I'm sorry this is happening to you and Twiggy

 

Edited December 10, 2011 by robinw

[Guest snakes]

It just feels like it never stops sometimes does it?

 

I would second checking for mouth sores, wasn't Twiggy on antibiotics for the post-amp infection? In humans being on antibiotics can often lead to thrush of the mouth/throat which can be very painful and annoying due to the antibiotics killing off the 'good' bacteria.

 

FedX was diagnosed with idiopathic epilepsy at 3yo, he is alert and will turn his head and attempt to follow me during the seizure, but his coordination is gone and his back end gets very weak/uncoordinated. He never had a spike in temperature.

The nuerology visit we had really didn't say much, we tried him on KBr but the side effects were too much for him. We ended up using homeopathic remedies which controlled his anxiety which are usually the root of his seizures. The nuerologist recommended an MRI, but it was ~$2500 and since i wouldn't have done any major brain surgery i felt it was a waste of time, money, and stress/aneasthesia for FedX. It wouldn't have changed the treatment I provided him.

 

I would tend to have your docs take a looooong look at all of twiggy's meds too, a lot of drugs have a lot of side effects and this could be one of them. I can liken it to humans who take psychiatric meds and often gets twitches or spastic muscle movements, sometimes/fairly commonly with the tongue.

 

I would be very careful adding in meds, especially with the chemo as interactions between meds gets very tricky. One consideration is that gabapentin (which i believe twiggy was on, maybe still is?) was originally used as a seizure control med in humans.....

 

Any other questions I should have but haven’t thought of yet? I’m pretty much a wreck right now. I wasn’t expecting this particular path through osteo.

 

Since she is still happy and energetic I wouldn't over worry about it (i know that is seemingly impossible!).

I think it is probably med related more than brain tumor but i am no vet and try to stay optimistic

[krissn333]

I don't have any additional advice, but I wanted to let you know I'm thinking of you

 

Just take it one day at a time, I think that I would do the MRI so you know what you're dealing with. Personally I wouldn't want to start any of my kids on anticonvulsant therapy if there's no chance for it to be effective in helping-those meds come with a whole set of side effects, which, if warranted, I would deal with, but I wouldn't try them unless I had proof that they were needed.

[DesiRayMom]

Prayers for Twiggy.......strength for you.

[duncan41]

I have absolutely no experience with any of this, but I do have lots of experience praying, chanting and sending healing thoughts. I'm working overtime for Twiggy. Hugs to you, Wendy.

[TwiggysMom]

Twiggy has actually been on very little medication (relatively speaking). She never had a Fentanyl patch (although she did receive fentanyl via iv while at OSU). After her amp, she was on Cephalexin, Tramadol and Rimadyl.

 

Her Pseudomonas infection was treated without antibiotics (it would have needed imipenem, which would have cost about a year's pay) - they excised as much surgically as they could, then she was hospitalized for 5 days with a VacTherapy bandage. After she was released, she had a course of Baytril to prevent any new incision infections while it finished healing.

 

In mid-October, she got a round of Clavamox for a UTI.

 

The only medication she is on now (aside from whatever carboplatin is still in her system) are two topicals to keep the yeast and demodex overruns on her nose in check. Those are miconazole nitrate drops and Goodwinol ointment. Twiggy's regular vet didn't want to give her anything systemic because she figured Twiggy has enough going on systemically already.

 

I have some Gabapentin for her, but she hasn't needed it, so she has never gotten any.

 

If the neurologist thinks it is a good idea, I will probably go with the MRI. We were planning to re-stage next week, anyway. Maybe I can work the MRI in at the same time (even though it is two different departments involved). You all know how I like to plan, and without info, I can't really do that (even though circumstances keep making me change my precious plans ) I hope he will be willing to bring Dr. Couto into the loop, since I think they used to be colleagues, and since her amp was at OSU. The neurologist's experience there was my final deciding factor for picking him.

 

Thank you for all the ideas, suggestions, and good thoughts. We really are having a wonderful time 95+% of the time. She is such a joy, and I worry so much about her.

[carronstar]

I have no ideas just lots of prayers and good thoughts for Teiggy and her frightened human.

[JJNg]

Personally I wouldn't want to start any of my kids on anticonvulsant therapy if there's no chance for it to be effective in helping-those meds come with a whole set of side effects, which, if warranted, I would deal with, but I wouldn't try them unless I had proof that they were needed.

Anticonvulsants are needed if there is frequent seizure activity, regardless of cause. They can help (to a degree) even if the seizures are caused by a brain tumor. So IMO, the main determination to make is whether Twiggy's episodes are true seizures.

 

I hope he will be willing to bring Dr. Couto into the loop, since I think they used to be colleagues, and since her amp was at OSU.

Why not go ahead and submit an OSU consult, rather than waiting to see if your neurologist will contact Dr. Couto?