Where Do We Go From Here? Up, Of Course!

So, two episodes of heart failure (5/2/08 & 5/19/08) resulting from fluid retention first caused by Prednisone and then Methylprednisone. Visit to Dr. Richter (internal medicine vet) and Dr. Orvahlo (cardiologist) on 5/23. The verdict: 3 month break from all steroids, continue with Leukeran, B12 shots, diuretic and start on half dosage of Enalapril for newly discovered mitral valve regurgitation. Check kidney function in 3 weeks. Follow up in 3 months. If cardiac function improved, then Budesonide can be tried as a replacement for Prednisone.

I brought Sally home, along with a tiny sliver of hope.

Thank god that Sally's been taking pills as long as she has!! Trying to poke 1/4 and 1/2 tablets down a 7 lb cat's tiny little throat is nearly impossible without the aid of Greenies Pill Pockets (which she won't touch) or a pill shooter (which has been my best friend since 1996).

We went back to ABC in 3 weeks for her follow up. This would be her very first CBC since starting Leukeran and Enalapril and I was a nervous wreck. If her white blood cell or red blood cell counts dropped, she would have to stop the Leukeran and all hope for her survival would be gone. If her kidney function was elevated, she would have to stop the Enalapril which was helping her battered little heart work better.

Finally! The first good news in 2 months!! Sally gained 6 ozs! Doesn't sound like much but it is when you're as small as she is. Yaay! All the hand feeding turkey 3-4 times a day was working! Dr. Hansche gave her the last of the four weekly B12 shots and drew blood for her CBC. Dr. Martin called the next day with the results. More good news!! Her white blood cell count dropped from the high of 26,000 to 16,500 (only slightly above normal). Red blood cell count normal. However, her BUN and creatinine levels were both elevated so Dr. Hansche would follow up with Dr. Richter to see if she should stay on Enalapril or not.

Mid week, Dr. H called to say Dr. R said to stay with the half dose for another 3 weeks and then re-check. 3 weeks go by with Sally continuing to vomit bile virtually every morning between 2-5 am. I had heard through the Yahoo Lymphoma group that cats can be given small doses of Pepcid to help with nausea and vomiting. I asked Dr. Hansche at her next follow up and he green lighted her for 1/4 tablet as needed. Another 3 ozs gained!! Dr. Martin called the next day. WBC down to 15,000 and RBC still perfectly normal. BUN and creatinine were still elevated but at the same levels as they had been 3 weeks prior. Dr. H followed up with Dr. R who said to try increasing Enalapril to 3/4 dose and follow up in 3 weeks to see how her kidneys were doing.

At this point, Sally had been on Leukeran for almost 8 weeks exactly. I had heard over and over that cats with small cell lymphoma took longer to show improvement on Leukeran, usually 8-10 weeks. As if by magic, right at 9 weeks, Sally turned a major corner. The daily vomiting stopped. Her energy level was better, she was interested in all her favorite things again, she began grooming herself again. She was now up to 7 lbs 13 ozs from her low of 7 lb 1 oz much to everyone's delight. I was starting to catch glimpses of my old girl again and nothing made me happier!

3 weeks and another CBC. Dr. Hansche was pleased at how much better Sally was looking. Another Sunday and another call from Dr. Martin with test results. WBC now 13,500, RBC normal, kidney function still elevated but still stable. Dr. Richter said to go for the full dose and check in 3 more weeks.

It was time for her 3 month re-check with Dr. Richter. With some anxiety, I scheduled her appointment for August 30th, the day before Emily's birthday. We were his first appointment that morning. I filled him in on her improvements and accomplishments. He wanted to do a follow up ultrasound to see how her intestines looked. He gathered her up and headed upstairs. I went out to the waiting room and held my breath.

About 20 minutes later, Dr. Richter came out with a look of complete surprise on his face. He uttered the words I couldn't have imagined hearing just four short months before: "No evidence of active cancer." Translation = REMISSION!! The layering and inflammation that had been so obvious in April were gone. All of her lymph nodes were normal. Pancreas normal looking. Kidneys looked about as expected for a cat with elevated values. But overall, he was amazed at how well she'd done on just Leukeran alone. He said that every trial he had ever seen had used a combination of a steroid and Leukeran and that the steroid proved to be the key component in achieving remission. He was frankly dumbfounded by her remission, but was pleased as could be with the outcome. He said she could now go to having her CBC done every 8 weeks and that she needed a follow up with Dr. Orvahlo to make sure her heart looked good. Obviously, no steroid was needed. She was to stay on Leukeran indefinitely.

I pratically ran out to the car. Who would I call first with the good news? Dorian? My mother? I sat in the car with her on the seat next to me and laughed and cried at the same time. I couldn't believe it! All of my hard work, tears and stress and Sally's determination and strength had paid off. My prayers had been answered! She looked at me as if I'd lost my mind. No one gives dirty looks better than a cat! Hers clearly said, "Stop that foolish noise and take me home!!"

So we headed home with something that had been absent for the last 6 months: hope for the future.

From Bad To Worse

Armed with a new prescription for Methylprednisone, I crossed my fingers and hoped for the best. The first three doses were uneventful but the morning Sally was due for her fourth dose, her breathing seemed a little off to me. My husband stayed home sick that day and promised to watch her so I prayed that I was overreacting, gave her the pills and headed off to work. All I could think was, "Please god, don't let this be a repeat of how she reacted to the Prednisone." Throughout the morning, he kept telling me that she was doing okay. By the afternoon, he said that I should make her an appointment to see Dr. Hansche to make sure everything was alright. By the time I got home, she was struggling to catch her breath and gasping for air. I gathered her up and jumped in the car. It was rush hour and the traffic was horrible. I just kept telling her over and over again that she'd be okay if she could just hold on, but the look she had on her face scared me to death. I was so afraid that I would lose her before we got to ABC Vet, but we finally got there and I rushed her in. They took her back to the oxygen cage right away and Dr. Hansche told me to come back in an hour.

It was the longest hour of my life.

When I went back, Dr. Hansche was waiting for me. He brought my baby girl out to me all wrapped in a blanket. He set her down gently on the table and kissed her head. Her breathing was better but still very raspy. Worried how she'd make it through the night, I had her care transferred to the same emergency vet she was at less than three weeks earlier. The ER vet was very negative about her chances. She used the phrase "gravely ill cat" and told me to prepare myself for the worst. Seeing her in the cage and having to say goodbye just tore me up. I cried so hard on the way home, I had to pull over on the side of the freeway because I couldn't see to drive. This was it. I was losing my girl.

With an emergency vet, no calls = good news. I called at 5:45 am to check on her and she was resting comfortably. I hadn't thought to bring her meds with me so I stopped by on the way to work to drop them off. They had Sally on the counter in a little plexiglass cage and she looked at me as if to say "get me out of here!!" Unfortunately, they had tried to wean her off oxygen and she didn't do well so they were keeping her on it for a few more hours. Later that day they had their cardiologist look at her and an echocardiogram showed some major structural changes. Sally got to come home that night around 9 pm.

Coincidentally I had a follow up appointment scheduled with her internal medicine vet the next day so we headed back down to VSH. Dr. Richter was pretty concerned about what condition her heart was in after two episodes of heart failure in three weeks. He took her upstairs to the UC Davis vet school to have their cardiologist do an ultrasound. While her heart looked better than they thought it might, he did notice that she had a leaky mitral valve. The medication she needed to take for it (Enalapril) was cause for concern because of the negative effects it has on the kidneys. Sally's kidneys had already taken a knock from the diuretic she was taking but we decided to try her on half the usual dosage to see how she'd do.

As far as her lymphoma went, Dr. Richter was not very optimistic. The steroid component of the chemo was directly responsible for remission and without it, Sally didn't have much of a chance. The Leukeran would slow the growth of new cancer cells and give her a couple of extra months but remission on Leukeran alone wasn't possible. The only chance she did have was a specialized steroid called Budesonide that is only absorbed by the intestines so would have a minimal chance of causing fluid retention. But first, she needed a three month vacation from ANY steroid to let her heart have a chance to recover and gain strength.

During the month of May, it broke my heart just to look at Sally. She was so skinny and frail. Her fur was dull and greasy and missing on her front legs, chest and stomach from where she'd been shaved for her many tests. You could see her little hip bones jutting out when she walked. (The picture at the top of this post was taken shortly after her second episode of heart failure.) She spent most of her time curled up on her birdy blanket. Every morning I was so afraid that I might find that she'd passed away during the night. About 6 weeks into her chemo, she began vomiting bile every morning between 2-5 am. My friends kept telling me that she was suffering and that I need to do the kind thing and let her go. But yet, as sick and weak as she was, she managed to wake up every morning and struggle through the day. I'd been warned by people in an online lymphoma support group that Leukeran took a long time to show results, usually 8-10 weeks. I know that people say you will "know" when it's your pet's time to go, but I think it's more that you realize that you've exhausted every avenue of treatment and you can't save them. I was right up to that point and didn't know what to do. I didn't want to take away her chance at remission because I was too impatient to see results. However I didn't want to string out her suffering and struggling because I couldn't bear to let her go. I always knew this choice would be difficult with her, but I had no idea HOW difficult it would be.