Remington's Hemangiosarcoma Cancer FAQs

November 4, 2002.

Hemangiosarcoma, manifesting as a large mass on his heart, extending into the heart's right atrium. It is a blood-fed, rapidly growing aggressive tumor. Can't be 100% positive because apparently if you cut into one of these, e.g. for a bioposy, patient will bleed to death. However, Vet says they're pretty confident of the diagnosis because there aren't many other things that show this kind of growth, behavior, and appearance in this location, and they see this kind of tumor in this location fairly often, enough also to predict how treatment will work.

The Dec '02 Dog Fancy magazine described it this way:

"With this aggressive cancer of the blood vessels, tumors commonly appear on the spleen, liver, heart muscle, and skin. German Shepherd Dogs are particularly susceptible [my theory has long been that Rem is part GSD]. Because of this cancer's tendency to spread, prognosis is usually poor."

As it grows and/or is disturbed, it tends to bleed into the sack around the heart. Eventually it ruptures or pressure on the heart causes cardiac failure. Untreated, best estimate for survival is maybe a month.

Best guess with our treatment plan is 5-6 months of survival, but a good portion of that should be at a decent quality of life and activity.

Main risks are:

• Tumor ruptures and he bleeds to death. There's no way to stop it--can only keep his body functioning, give transfusions, and hope for the best.
• Pressure on heart becomes too much as tumor grows and he has cardiac failure.
• Cancer metastasizes to other organs (usually first into the lungs) and they fail or he becomes too sick to function.

Chemotherapy to try to reduce the size of the tumor to decrease the likelihood of ruptures & decrease its own pressure on/invasion of the heart.

He's getting 2 kinds of chems (and occasional antibiotics):

• Adriamycin, which is given intravenously and was the first thing he got. He'll get that about every 3 weeks. 20-30% of dogs have gastrointestinal upset from this medication. (Mar 2: Remington sometimes showed a little loss of appetite for a couple of days, but not much.)
• Cytoxan, which is given in tablet form, one pill for 3 nights running. He gets that twice between adriamycin doses (so altogether he's getting something weekly).

After all of this, at some point this kind of agressive & fast-growing tumor tends to build resistance and stop reacting to the chemicals. Then we try different chems, if there are any that might be helpful. Repeat until the tumor starts growing again & there's nothing left to try, then there's really nothing to do after that.

Risk from the chemo is that it can greatly reduce the white blood cell count, which opens the dog up to an elevated risk of infections from various other sources. So they do a blood test a few days after every dose, and if necessary prescribe antibiotics as a preventive measure if the white blood cell count goes too low. (Mar 2: Rem's white blood cell count was almost always low enough a week after each adria dose that they always held off on the next dose of cytoxan and instead gave about 10 days of preventive antibiotics.)

Update Feb 28: He received his 5th and probably final dose of adriamycin Feb 18. It seemed to help stem the bleeding that was going on then, but it started up again on the 24th. Also seemed to make his tummy a little queasy for about 4 days.

At that point, Rem had received the maximum total dosage that they generally like to give dogs, about 150 (measurements?); they will do more if they think it helps, but by about 240 total dosage, most dogs have developed serious coronary problems.

My concern was quality of life--would Rem be miserable from the chemo? Vet said that some dogs aren't bothered much by it at all; most others have 2-3 days of not feeling well for each treatment (every 3 weeks) but in between feel much better than they would have otherwise because the tumor is becoming smaller.

Rem has reacted very well through today (January 3). Some diarrhea occasionally, perhaps a little upset stomach, but no other physical or behavioral symptoms.

Adriamycin has really knocked out his white blood cells each time; this is risky because he's more susceptible to other infections (he gets antibiotics each time they're that low), but it's also a good sign that the chemo is working. Since it's designed to wipe out rapidly growing cells, and white blood cells are such, it's a good sign that it'll do a good job on the tumor, too.

Ultrasound on Dec. 17 showed that tumor has shrunk enormously, much more than expected, maybe 70% smaller. Vet seemed extremely happy. Mar 2: Yet it started bleeding again just a week later. At the next ultrasound a month later, the tumor was back to about where it had started. So we gained maybe a few weeks but not as much time as we had hoped given the first month's results.

Yes. On Nov 6, South Bay Veterinary Specialists (specifically, Dr. Parchman and Dr. Daugherty) performed a thoracoscopy, where they use slight incisions and a scope on a rope (my terminology) to cut a window in the pericardium (sack containing the heart), which will be left open to allow fluids to drain into his chest, where they should be reabsorbed by the body.

This is good for when the tumor ruptures. Instead of building up pressure on the heart and causing distress and possible heart failure, the blood drains away from the heart. Body can actually reabsorb the blood if it's a slow enough leak, which means he won't need as much in the way of transfusions.

Opening a window in the peridardium for this situation is standard.

However, until recently--and still in some places--the way to do this is with major chest surgery. Rem's operation is a fairly new procedure--thoracoscopy--where only a slit or 2 are cut in the chest cavity and thin tubes are inserted with scope & knife to do the operation. Pain, risk of complications, and recuperation time are greatly reduced over the old way, although if something goes awry, they still might have to open up the chest the old way. With this method, Remington comes home after about 36 hours instead of 3 or 4 days, or more, later.

For this new method, which has apparently been around only a year or 2, there's one surgeon in L.A. who's apparently done it hundreds of times, and the surgeons here at South Bay have done it dozens of times and are the most experienced at it in the Bay Area--they say that they've done it successfully every time so far. But it's still a unique treatment; Rem is semifamous in the clinic's community for having had the operation, which many of the other vets and vet techs wanted to watch.

Vet says that Davis does some surgery for this kind of growth, but not much because the risk of bleeding to death is extremely high, it's major surgery which is also high-risk on its own, regrowth is very likely, and the overall results & quality of life don't tend to be any better than the course of treatment they're recommending.

Mar 2: If it occurs on the spleen or liver, it is possible to remove the organ along with the tumor (if it doesn't rupture and kill the dog on the operating table), which, if early enough, might prevent metastasizing and also make chemo more effective.

Mar 2: However, from what I'm learning, hemangiosarcomas often aren't diagnosed until fairly late because the dog shows no symptoms until it's large enough to rupture. So surgery is a risk, too.

Not very successful on this kind of tumor; also can't use it on tumors in vital organs like the heart because it tends to damage the surrounding tissue as well.

Yes.

It's not clear to me from reading the sample policy that one company sent me that I'd get enough back to break even after making payments in the vicinity of $300/year through the dog's life. With the limits on repayment for various treatments and conditions, at this point I *might* have gotten back my 9-year investment (if I had paid it), but not sure about that. I'm working on an analysis.

Remington became very ill the evening of Nov 4. Something like what we saw down at West Valley at the end of August--no energy or enthusiasm, refusing food, severely dehydrated. He seemed fine in the morning on our walk, although we didn't do anything really active, and he wolfed down his breakfast.

Around 5:00, though, before dinnertime he was quite listless. No interest in practicing agility or even doing tricks, his favorite. Refused regular dinner, took a couple of treats reluctantly, but slurped down the half a jar of babyfood I offered.

As the evening progressed, though, he refused all food and drink, and he would stand hunched over, sometimes just standing in the middle of the patio for 10 minutes at a time looking miserable, sometimes right against my feet (as you might know, he's not a real snuggly dog usually) and standing up, lying down, standing up, lying down, turning around--and when he did lie down for a few minutes at a time, he just whined under his breath with every breath--and he's such a stoic about pain & discomfort, I knew he had to be hurting real bad. His gums looked like he was working on being dehydrated again, as he was in August.

I finally took him in to the emergency room. They gave him fluids and ran some tests. Ruled out gopher poison (which I was afraid he'd encountered while digging yesterday--I don't know what previous owners might have left in the ground). Signs of internal bleeding, though; temperature very low, heartbeat very rapid, severely dehydrated, heart enlarged & probably fluid filled. Xray showed some unusual mass, which was the first time we suspected.

What got Remington then and probably back at West Valley at the end of August (best guess), is pressure on the heart from fluid & bleeding from the growth backing up inside the pericardium (sack around the heart) putting so much pressure on the heart that it can't pump properly. His heart rate had elevated to 200/minute by the morning of Nov 5 before they drained about 500 CC of fluid from there.

Mar 2: From what I'm hearing from other folks, the tumor rupturing is how most hemangiosarcomas are diagnosed. In a period of maybe a couple of hours--or less, depending on the severity of the rupture--dog goes from being an active, healthy, normal dog to being extremely lethargic, head and tail down as if in misery or pain, doesn't want to eat or possibly even drink. Blood test shows anemia (low red blood cells). If it's a heart tumor, as Rem's was, heartbeat might be quite elevated because of the fluid placing extra pressure on the heart and making it difficult for it to function.

Unlikely. Maybe in late August, but we treated the symptoms and he got better quickly.

This type of thing is usually very aggressive & very fast-growing, so it could've been around only a couple of months or several months longer; with no previous xrays or ultrasounds or anything to compare it to, we'll never know when it started.

Doctor says tumor is large enough, and with Remington's very active lifestyle, that it's "amazing" that it hasn't already ruptured and killed him. It's also amazing that he's shown few symptoms, although there are lots of little and a couple of larger things recently that are now explained. He always was a stoic on discomfort & pain.

Tough question. This and any intense activity increases the risk of a rupture, not only because of the type of tumor but because of its location on his active heart muscle. I hope that the risk is somewhat less because he's been a pretty active, fit dog and his heart should be fairly strong and so won't get quite as "exercised" even when doing hard running or jumping.

Right from the beginning, vet has pointed out that the only reason to go to all this effort to keep the dog alive is so that he can lead a happy, relatively pain-free and comfortable life and do the things he enjoys doing. So I have to weigh that against the risks inherent in what he loves doing, which is running around like crazy chasing squirrels in the park, doing exercises in our weekly agility classes, and even doing agility at competitions.

We've been to class only once since his operation, and he did fine. Maybe not as fast as before. But I let him decide whether he felt like running. Ran him at 12" jumps (which is half the height he normally jumps), and I didn't run him for an entire class, and he really really didn't want to go back in the car when we stopped.

At agility competitions--where I plan to continue to go, with 2 other dogs who are happy & healthy & rarin' to go--he usually doesn't even lie down or rest until he's had his first run of the day. So my plan is to enter him in a small number of runs each day and play it as it comes. Take him out to the start line for the first run of the day if he's looking chipper & active & OK over the practice jump, and see how he goes.

I still think it would be wonderful if he could finish his MAD before he goes--just 2 cruddy standard legs!--but my goal now is for him to enjoy being out there, or to take him off course if he's not feeling up to it.

Update Feb 28: His last agility trial was a CPE trial, where he jumped 16", Feb 8-9. He didn't run fast, but seemed eager to be on the course. After he started bleeding again the following weekend, I officially retired him from agility on Feb 18.

I am feeding him Hills Canine n/d canned food; designed for dogs with lymphoma based on research done by Morris Animal Foundation

He's also taking antioxidant supplements.

There are some risks involved in these, but very low risks and, for the most part, I believe it can't hurt and, who knows, might help.

There's a brief article on special food & supplements in Dog Fancy online.

Update Feb 28: When he's bleeding, he has no interest in any food except real meat, chicken or beef. (Chicken or beef baby food is fine, too.) When feeling a little better between bleeding, he was also willing to eat chunky chicken canned dogfood, but he pretty much has shown no interest in the Canine n/d since Feb 16, when he was clearly bleeding internally and weak.

Not entirely. First I managed to run him over a large piece of broken glass, which sliced open his foot and ankle, and he was in bandages and a splint for most of November.

On Xmas eve, he looked ill again and I took him in to the emergency room. Normal red blood cell count is 37; he had dropped from 36.9 the previous a.m. to 30 Tuesday p.m., and it continued to drop, indicating internal bleeding.

At some point they confirmed blood in his chest cavity with a needle aspiration.

They kept him at the hospital for almost 48 hours. By Xmas night, his red blood cells had dropped to 17 and they gave him red blood cell transfusion to ensure that his body still could move oxygen around. He perked up immediately, which apparently transfusions will do (although they don't cure things).

Fortunately, his *white* blood cells were OK, so they also gave him an IV of adriamycin 4 days early to give the naughty tumor a big whup upside the head.

The bleeding apparently stopped because he stabilized around 24-25. Came home the evening of the 26th. On the morning of the 27th, his count was up to 30 and we declared the immediate crisis done with.

Updated Feb 28: Had another period of lesser bleeding in January; I'll have to look up the dates. Again started bleeding in mid-February; I was certain of it by Sunday the 16th because he was weak, disoriented, and showing grayish rather than pink gums. Got down to about 17 before we could get him a transfusion. Seemed to perk up for a few days, then started bleeding again Monday the 24th. Got down to 22 by Thursday the 27th; up a little to 24 on Friday morning and he looks a little perkier but not energetic.

When the tumor ruptures, it bleeds internally. Only ways to tell are lethargy, pale gums (Rem's got actually almost white on his worst bleed), white whites of eyes (usually you can see some red and veins). Some dogs' tumors rupture in a major way and they can bleed to death before they can even get to the vet.

Rem's ruptures seem to be slow leaks, at least so far. A normal red blood cell percentage is about 36-55. In a typical case of a dog losing blood, a transfusion is done somewhere between 15 and 20 depending on how quickly the dog is bleeding.

The challenge with transfusions is that dogs (like people) can develop antibodies to this foreign substance in their body. Reactions to a first transfusion are fairly rare, but with each transfusion, the likelihood of finding a good match can keep dropping. If you're in an area that's lucky enough to have a dog blood bank, you might find matches, or you might not. If you live in anywhere other than a larger urban area where this is practical, you might get one transfusion from a randomly available dog and then after that it's touch and go.

You can transfuse various parts of blood. I don't know the story on all of them. Red blood cells don't help clotting but they do keep something in the dog's system carrying oxygen through his body while you hope that the internal rupture stops on its own. You can transfuse platelets, which do help clotting, but for these hemangiosarcomas the problem isn't a lack of clotting factor in the blood, it's a grody tumor that's breaking apart in some way. So platelets aren't likely to help.

Many people had told me that I would just know; that he would tell me in some way. I expected that perhaps he'd stop eating, or he'd stop bleeding again and not stop, and I had already decided that he wasn't going to spend any more of his last days on earth alone in the hospital with IV tubes stuck in him. In fact, this was the key decision in helping me to get through what came next. The vet had encouraged me to pick certain things I would or wouldn't do, or a certain number of times that something would occur, or something to give myself guidelines for when it was time.

Instead of any of the quiet ways, though, I was propelled into the decision by the horrifying experience of being woken in the night by a tremendous, silent thrashing all across the bed--turned on the light to find Remington having a violent seizure. I didn't know what it was, what had happened, whether he couldn't breathe or some other horrible thing that I couldn't have imagined. It probably didn't last a minute, but it terrified the other dogs, and me, and possibly Remington, as well. When it slowly stopped, he lay on his side, head in my lap, taking deep breaths, eyes wide and pupils gigantic.

I decided that it must have been something caught in his throat (I had no idea what a choking dog would act like--vet reassured me afterwards that it was *not* like a seizure), and tried to settle down again, but couldn't sleep. Didn't even want to turn out the light. He followed me downstairs, a bit wobbly but otherwise normal again, when I went to get something to drink. When we returned to bed, I jumped at his every twitch or change in position or breathing.

Just over three hours later, he abruptly thrust himself up into a sit, his back stiffening, his face contorting. I tried to grab his collar to steady him, to do something, I didn't know what, and he yanked his head away from me, and then went into another violent spasm, throwing himself so hard around on his back and sides and everywhere that he somehow got past me, all the way across a king-size bed, and over onto the floor.

Again it stopped. Again I stroked him for maybe 10 minutes while he recovered. But by then I knew that this was the end, unless the emergency room could come up with some miracle answer as to what was causing it and how to fix it. I couldn't bear for him to go through that again, and I had no idea how often it would happen, nor whether the next time it might actually kill him. *I* couldn't bear to go through it again.

I took him to the emergency room and then, as now, I found that I couldn't say "put him to sleep." It just wouldn't come. I was trying not to bawl and not succeeding. Closest I could come was "I think this is the end." Fortunately the doctor on duty had met us once before, and she was able to decipher my utterances.

She said that what I was describing was a seizure, not a choking dog. Because there were so many possible causes (see next question), none of them good, the best they could offer would be to keep him at the hospital and monitor him and try to apply anti-seizure drugs if it happened again and see whether they worked.

That sounded like a sucky way to spend his last day, if that's what it was going to be. I knew he wouldn't be happy for that. So--it was the end.

That was the long answer.

I wish that I had known about this possibility. The 3 vets I talked to afterwards all said that this wasn't a common or likely outcome from his cancer in his location. But they did agree on some of the things that can cause seizures in a dog with cancer (as our vet said, "all nasty stuff"):

• Heart arrhythmia (which in itself can be caused by a number of things; in my dog, with the tumor right in the heart, it seems likely)
• Liver or kidney failure can release toxins into the bloodstream
• Metastasizing into the brain
• Metastasizing into the lungs, so that not enough oxygen gets to the brain
• Various other things might prevent enough oxygen from getting to the brain
• Rem seemed to have some kind of upper respiratory infection the week leading up to this--sneezing and yellow discharge--could have been because of lowered immunity; if a viral infection, this also could have spread to the brain.
• And it occured to me much later that he could have suffered some heart damange from his fifth dose of adriamycin nearly 3 weeks before. Vets did say that by the 6th, most dogs start to suffer some kind of cardiac damage. I haven't confirmed this with the vet as a possible cause.

Despite the terror in the night, I am so glad that (a) I was with him, (b) I was at home (we had been scheduled to be out of town in a hotel that night, but I decided to stay home and leave early in the morning instead, (c) we weren't in the car--which we would have been, 4 hours later, on the freeway, in the dark.

I stayed with him. The vet spread out a blanket on the floor, which he lay down on gratefully. They had put an IV connector into his arm first thing when we got there in case he had another seizure while we were talking to the vet. So I just stroked him while the vet injected the anaesthesia. It was amazingly quick--his head just sank comfortably onto his feet like he was going to sleep, and then everything just stopped.

The vet and friends had warned me about the last effects of involuntary muscle spasms, so when his lungs reflexively gasped a couple of times after that, it didn't bother me.

It was so hard to believe that he couldn't just get up and walk out with me. It is very hard to remember him lying there, all him, looking and feeling the same, but not breathing. It is painful now for me to remember this clearly enough to write about it, but I hope this will help someone, sometime.

I've lost 3 dogs now, in 3 different ways, and I think that I will feel most comfortable in the long run about being there while the vet put him to sleep.

Our first dog died in the night, downstairs, alone, and although we had no way of knowing, it's been hard for me to forgive myself for not being there with her.

Our second dog couldn't walk when we took her to be put to sleep. The vet said that he usually suggested that people not be with their dogs for the final injection because of the twitching and gasping from the involuntary muscles, and we decided to follow that suggestion. So my last memory of her is the vet carrying her away from us, sagging in his arms, eyes watching us as the door closed. I will never stop feeling guilty about that.

Rem's reactions to the chemo treatments were extremely mild. Mostly I didn't notice any reaction, except that sometimes (not every time) he had some diarrhea, and sometimes (not every time) his appetite wasn't up to snuff--but he *never* turned down cooked chicken. And the vets had suggestions to help alleviate the diarrhea and the unsettled tummy when they did occur.

Rem's tumor definitely shrank with the chemo treatments for at least a month after it was discovered, but it came back within a month or so after that. My vet's initial prognosis was that I'd be lucky to get 5-6 months with Rem's tumor as large as it was and in the location that it was; I got 4 months and the majority of the days were good to very good. (Although actually if you take it from his abrupt illness over 2 months earlier that was never diagnosed and which I'm sure was the tumor's first attempt to make itself known, I actually got just over 6 months with him.)

The first 6 weeks after his initial treatment, he was more active and energetic than he had been for probably 3 or 4 months before that; then the tumor bled internally and he needed a transfusion, then within a week he was completely back to his normal energetic self--ran a couple of very fast agility rounds, although he tired more quickly, and that lasted probably another month. After the 2nd round of internal bleeding, he never came back to his old energy levels. But I think that was the tumor(s) on his heart more than anything else.

It seems to me that every time Rem got a dose of adriamycin, it gave the tumor(s) a big old whup upside the head, stopped any internal bleeding, and allowed him to pick up and carry on for a while longer. They can do that only so many times, though, because adriamycin can cause cardiac damage after too many treatments.

Different breeds and different dogs have very different reactions to chemo, from what I've heard & read & experienced from among my friends' dogs who've had cancer. Another friend's dog also has hemangiosarcoma & has had 4 treatments of adriamycin, and she says you couldn't ever tell that this is a sick dog getting chemo treatments.

I was extremely grateful for the good times we gained as a result of the treatment, but there are tradeoffs.

I think I would do it again in the same situation, but I'm not as 100% sure as I was when we started. Maybe 95% sure. All of the things that Rem went through ended up being very expensive, which I don't regret having spent on him to give him comfort and the opportunity to dig up more gopher holes, but in some ways I wonder whether the very short 1,2,3, or 4 months it bought were in our best interests. By the end, I was so stressed about whether it was time to decide to put him to sleep, or whether the tumor would start bleeding rapidly suddenly and I'd lose him at some terrible time and place, like while out of town at an agility trial, or whether he was enjoying things more than he was feeling tired and not so hungry--that I could hardly sleep or concentrate on anything else. And I don't know whether my stress level made it worse for *him*.

But I guess that that time comes either sooner without treatment or later with treatment. Because of the treatment, I did get a chance to take him up to the woods in Oregon, which I had always thought I'd do eventually, but the urgency became apparent when he was diagnosed; I had a chance to videotape him doing his huge repertoire of tricks; I did get to spend some time with just him alone and not with the other dogs; he did get to visit with many of his human friends over time, who all gave him attention (and food) and affection; he did get more opportunities to play and run and dig at gopher holes and look intently at Cows.

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