Something's going on with Milo

[EllenEveBaz]

Another dead rabbit yesterday.  In the house.  With no head.  

[ramonaghan]

12 minutes ago, EllenEveBaz said:

Another dead rabbit yesterday.  In the house.  With no head.  

But did you add sauerkraut?

[palmettobug]

Hassenpfeffer, anyone? 

[EllenEveBaz]

 

 I suspect that Gelsey is the gourmet gourmand in this case.  

[2greyhoundMINI]

So late to this, but caught up and wishing you good luck. And hope you figure things out! 
 

Oh, and the headless rabbit? Ewwwwwww

My girls thankfully have never got one in the house. 

[EllenEveBaz]

UPDATE:  diagnosis

So Milo evidently has chronic lymphocytic leukemia (CLL), which is the best of the all-bad possibilities.  I had been afraid to hope for CLL, because evidently it's rare compared to any of the lymphomas.  He also has high globulin in his blood that Dr Couto recommends testing -- don't know if that's a side effect of CLL or a separate problem.  Haven't talked with the vets yet -- evidently the main question will be whether to treat or not.  Reading the info on the recommended chemo made my hair raise on end -- you wear gloves to give this (orally!) to your dog and you're not supposed to snuggle or sleep with your dog during the treatment period.  Just in case you weren't aware that you're giving your dog poison.

So that, and the side effects (which of course are  ) have to be weighed against the fact that Milo obviously doesn't feel good.  

Dr Couto's interpretation below:

 

Quote

 Milo's IPT is diagnostic for a CD8+ (cytotoxic T-cell) chronic lymphocytic leukemia (CLL). Most dogs with T-cell CLL have an excellent prognosis, and can go untreated for months to years. Most dogs live their normal lifespan with almost no clinical signs (symptoms). A very small percentage of dogs develops Richter’s syndrome, an aggressive large cell lymphoma that is very difficult to treat. For reference, I have seen hundreds of dogs with T-cell CLL, and only 2 dogs with Richter’s. 

I use the following criteria to implement treatment:

1. The are sick (and I can attribute the clinical signs to the CLL)

2. They have organ involvement (mainly hepatic/splenomegaly)

3. They have cytopenias (anemia, neutropenia, thrombocytopenia) or a monoclonal gammopathy

I typically treat them with CHLORAMBUCIL (20 mg/m2, PO, q2 weeks); I use any of the compounding pharmacies, since getting the 2 mg tabs in a pharmacy is cost-prohibitive. If they are symptomatic, I add PREDNISONE (20-40 mg/m2, PO, q24h for a week, then half the dose q48h). Most Greyhounds (I don’t know about lurchers) do not handle these doses of pred well.

Because his globulin was a bit high (at least for a Greyhound), I would also consider running a serum protein electrophoresis to see if he has a monoclonal spike; if that is the case, we should start treatment now.  The main issue with Milo is whether his behavioral issues could be related to the CLL (I have never seen that as a manifestation).

 

[ramonaghan]

So glad you have a diagnosis and that it's treatable (even if the treatment is a little scary). BTDT with the oral chemo and gloves, but we weren't told no snuggling (though Sweep's sleep startle prevented that anyway). We also had to promptly dispose of her poop and were advised to double-bag it. Though I don't have experience with chlorambucil, we had her on two other oral chemo meds (separately) and neither caused any side effects.  

[LBass]

Having a diagnosis at last is wonderful.  that the treatment decisions will become clear and that Milo will begin to feel better.

[MerseyGrey]

So not the best news but at least you know what you’re dealing with, so you’re over the first hurdle. I have it somewhere in the back of my mind that the disease progression in humans is quite similar- it can be indolent for years and never cause *too* much trouble for many, but for some unlucky few it can transform and become quite nasty.    for Milo and you that you fall into the first category

[FiveRoooooers]

[2greyhoundMINI]

It’s not so scary… our Sidney was on Chemo for a while. Had to do the same thing with the meds, etc. 
It sort of becomes routine. 

Good luck! I hope Milo starts feeling better!

[EllenEveBaz]

We are going to go ahead with chemotherapy, even though Milo's problems appear to be mostly cognitive and not effects of the chronic lymphatic leukemia.  At least I know what I'm getting myself for Christmas this year. Here is Dr Couto's assessment of low risk of side effects vs risks of not treating:  

Quote

 the probability of adverse effects from chlorambucil at therapeutic doses is minimal (infinitesimal?). I have treated several thousand dogs (and dozens of Greyhounds) without any appreciable toxicity. Honestly, I don’t remember the last time I saw toxicity in a dog (cats are different).

Hope this helps, and as you said, “to treat or not to treat” is the million dollar question. As a clinician, I like to treat patients, rather than test results, but…

If the SPE spike is monoclonal, as I suspect it is, it can result in neurologic problems, bleeding, renal deterioration, immunodeficiency, etc. 

 

 

Just for fun and light reading, here is him trying to explain some of the earlier measurements:

Quote

 

I reviewed the tracing and I am concerned that the “alpha-2 spike”  (see red arrow in attached figure) may actually be in the beta region, and it may be clonal in origin (the “cuts” in the tracing are made visually, so they are a bit arbitrary). IgA (at least in people where there is more evidence) can migrate in the beta region, and I have seen quite a few dogs with beta monoclonal gammopahies over the years.  It is uncommon to have such a high alpha-2 spike without marked increases in the gamma fraction and moderate increases in alpha-1 fraction(and Milo doesn’t have that). 

The only ways to prove this are by either doing immunoelectrophoresis (I don’t think that it is commercially available) or by quantifying immunoglobulins (if the IgA is really high, then it is likely a monoclonal gammopathjy). However, some dogs with IgA gammopathies have abnormal immunoglobulins that may not be detected by the assay, and consequently they yield a normal (or low) value. An indirect way to confirm that the alpha-2 spike is due to inflammation is to request a C-reacive protein (CRP) in the sample where they run the SPE (if they have any left in the lab); if the CRP is high, that tends to support inflammation (although some lymphoid tumors can also results in increases in CRP). 

In other words, Mr. Milo continues to challenge us. Please let me know what you think; thanks again and hope that Milo continues to do well.

 

Quote

 

There -- doesn't that make it all clear?   We did run the C-reactive protein test and while that was not absolutely definitive, Dr Couto thought it was informative enough that it was time to fish or cut bait on the treatment decision.  

Milo is continuing being a model of good behavior at the vet's office, for which the staff are duly grateful during all of these blood draws for the tests.  He's also continuing to want to be outside for long periods and not eat a lot.    

I feel very comforted when I re-read the posts some of you have made in this thread about the relative ease of chemotherapy.  Thank you.  

 

 

 

 

[ramonaghan]

 Clear as mud! I hope with treatment, you will see improvement in Milo's symptoms. Sending warm wishes to you all, and we're here if you have questions about chemo.  

[2greyhoundMINI]

Whaaaaaat?

Well, you do what you need to do 

[Remolacha]

I stopped reading after the first couple of sentences  The gist seems to be Dr C thinks the treatment would be beneficial with little or no side effects and not treating could cause more problems. That would be good enough for me! I hope the treatment helps Milo feel better 

[FiveRoooooers]

7 minutes ago, Remolacha said:

I stopped reading after the first couple of sentences  The gist seems to be Dr C thinks the treatment would be beneficial with little or no side effects and not treating could cause more problems. That would be good enough for me! I hope the treatment helps Milo feel better 

 

[LBass]

20 hours ago, Remolacha said:

I stopped reading after the first couple of sentences  The gist seems to be Dr C thinks the treatment would be beneficial with little or no side effects and not treating could cause more problems. That would be good enough for me! I hope the treatment helps Milo feel better 

Warmest good wishes that the treatment will help Milo.

[EllenEveBaz]

Milo had his first chlorambucil chemo pill yesterday with no ill effects as far as I can tell.  He gets a 19 mg capsule every two weeks, so there shouldn't be any build-up of side effects.  The chemo will not get rid of the chronic lymphatic leukemia (CLL), but we hope it will keep him feeling acceptably good for as long as possible.

Partly because of the 2-week interval, the cost isn't nearly as much as I had feared.  Having 8 capsules compounded to his exact weight dosage and shipped packed in ice costs a little over $100 for an almost four-month supply. A bargain.  

[ramonaghan]

 Keep up the good work, you two. 

[Remolacha]

I hope this keeps him feeling good for a long time!

[Time4ANap]

Yay for no side effects!  You're doing great, Milo! 

[Houndtime]

Here's hoping Milo feels better soon.

[FiveRoooooers]

 This is great! Kept it going you two 

[macoduck]

Love you Milo! 

[Patsy]

Hang in there sweetie.