Itsy’s Lymphoma

 D. E. Larsen, DVM

I looked again at Itsy’s tonsils. They were huge. Large tonsils and diarrhea equaled salmon disease in my mind until I proved otherwise.

But Itsy’s tonsils were not simply enlarged; they were huge. Opal stood wringing her hands on the other side of the exam table. She knew me well enough to know that I was concerned about something when I was quiet during an exam.

I started checking Itsy’s lymph nodes. They were all huge, even nodes that were not obvious in many dogs.

I looked at Opal. “She hasn’t had any salmon?” I asked.

“No, there hasn’t been any fish in our house for months,” Opal said. “What do you think is wrong, Doctor Larsen?”

Opal was an older lady, and she liked to keep her relationship with me on a somewhat formal basis. She had no problem calling me at night when Itsy spit up on the carpet, but she always addressed me as Doctor Larsen.

Before I answered Opal, I palpated Itsy’s abdomen. I could feel large lymph nodes all along her intestinal tract.

“Opal, I am going to look at an aspirate from one of these lymph nodes,” I said. “All of Itsy’s lymph nodes are very large. We just have to figure out why.”

“This is something bad,” Opal said. “I can tell. When it is bad, you get very quiet and serious looking.”

“Opal, I am going to do an aspirate first,” I said. “Then, if necessary, I will collect a biopsy from this lymph node.” I pointed to the left prescapular lymph node.

“Biopsy,” Opal said. “You think this is cancer. Oh, my God, what will Bitsy do without Itsy?”

“We don’t have a diagnosis yet,” I said. “Let’s make sure we have something to worry about before we get upset.”

Itsy and Bitsy were litter mates, adopted by Opal the day after Mucho died. I looked at them the same day. A couple of puppies that would fit into a coffee mug. They were not much to look at, but they have become Opal life.

I clipped some hair over the large prescapular lymph node. Prepped it with Betadine and stuck a twenty-gauge needle into the node. I twisted the needle a couple of times and withdrew. Then, with a syringe attached, I squirted the sample onto a microscope slide. After a quick stain, I put the slide under the microscope.

It was bad. In my mind, a definite lymphoma. I knew from experience that the pathologist would not make a diagnosis from a smear of an aspirate. He would want a biopsy.

When I returned to the exam room, Opal had Itsy on her lap and hugged her to her chest. Opal’s eyes were moist, but no tears were evident.

“Opal, this looks like Itsy has lymphoma,” I said. “The pathologist will want a biopsy to confirm that diagnosis.”

“I don’t know what you mean when you say lymphoma,” Opal said.

“Lymphoma is a cancer of the lymphatic system,” I said. “It is lymphatic leukemia. Lymphoma is a serious disease Opal. A dog with lymphoma will die from that disease. We can do things to make her feel better and to buy some time, but that is all.”

“I want to do what is best for Itsy,” Opal said. “I want to buy as much time as possible.”

“Okay, then we need to get a biopsy,” I said.

“If we know what it is, why do we need a biopsy?” Opal asked.

“If we are going to do what is best, I will send you to Eugene for treatment,” I said. “They will require a diagnosis from a pathologist, and the pathologist will require a biopsy. The biopsy won’t take long. I can do it right now with local anesthesia. That way, we can get an answer from the pathologist by the end of the week and start treatment at the same time.”

“Can you give Itsy something to make her feel better until then?” Opal asked.

“Now we get into some serious questions,” I said. “Chemotherapy is not the most pleasant treatment in people and dogs. We could give Itsy some prednisone now, and it would make her feel better right away. But the downside is that it often makes the chemotherapy less effective. So that is sort of a quality of life issue. We can make Itsy feel better, but that may reduce the time we can buy for her.”

“How much time are we talking about, Doctor Larsen?” Opal asked.

“I’m afraid not much time,” I said. “You never know, but if we use prednisone, we seldom buy more than a month or two. With chemotherapy, they use a nineteen-week treatment program. That usually gives Itsy a remission. How long that remission lasts is always variable. It might last six months or more if we are lucky. I have not seen it last a year. When the lymphoma returns, the second course of treatment is seldom as effective as the first treatment. My patients who have gone for treatment have all survived the nineteen weeks of treatment. Some remissions have lasted only a week or two. And in those cases, the patient did not survive the second course of treatment. I have only seen one patient survive nearly six months following diagnosis.”

“That’s not much time, Doctor Larsen,” Opal said. “I don’t know what to do. If you send me to Eugene, I would guess it will be expensive.”

“Yes, I don’t know how expensive, but the last couple I sent down there gave up their second car and their cell phones,” I said. “Their dog went into remission, but it only lasted a few weeks. And the dog died a couple of weeks into the second treatment.”

“What would you do, Doctor Larsen,” Opal asked, tears streaming down her face.

“I can’t answer that question for you, Opal,” I said. “You know your finances, but more importantly, you have to understand what Itsy means to you and Bitsy. It can’t be an easy decision, but you must make it.”

“Okay, let’s do it,” Opal said. “You do the biopsy, and I will take Itsy home and wait for your call.”

We took Itsy to the treatment table and clipped a wide area around her left shoulder blade. After prepping the site, I injected some lidocaine for local anesthesia. Itsy looked at me out of her left eye as Terri held her down on the table. I made a short incision over the swollen prescapular lymph node. Then with a six-millimeter biopsy punch, I collected a good sample and placed it in the formalin bottle.

There was no significant bleeding from the biopsy site. That was probably an indication of the unregulated growth in the lymph node. I closed the incision with three simple sutures.

“I wouldn’t expect Itsy to have any problems with this incision, but call if she does,” I said as we returned Itsy to Opal’s lap. “If you haven’t heard from me by Thursday afternoon, you should call. I am going to build a fire under everyone, so I expect you to have an appointment in Eugene on Friday, and the pathologist should have his work done by then.”

***

The diagnosis came back as an aggressive lymphoma. Opal took Itsy to Eugene, and they went through the nineteen-week treatment protocol. 

Itsy did go into remission, but after almost five weeks, Opal called the clinic in tears.

“Doctor Larsen, Itsy is all swollen up again, and she is not feeling well,” Opal said. “She looks at me, and her eyes say, please, don’t do that again.”

“What do you want to do?” I asked. 

“Maybe you can give her some of that stuff buys a week or two of good days,” Opal said. “If we can have a few good days together, I think we will be ready to say goodbye.”

“That sounds like a good plan, Opal,” I said. “You bring her over, and I will start her off with an injection and then send you home with some pills.”

Opal and Itsy were in the clinic within the hour. I gave Itsy a large dose of dexamethasone for an initial dose and sent them home with some prednisone tablets.

“Opal, this is a good plan, but for it to work well, you will have to decide to say goodbye while Itsy is still feeling well,” I said. “If you try to wait too long, she will be sick again or even die suddenly.”

“We just need a few good days, Doctor Larsen,” Opal said. “I just want to see her eyes dance with joy one more time. And Bitsy so enjoys it when Itsy is feeling well.”

Only a few days later, Opal brought Itsy in for her final visit. Everyone was at peace. Opal and her husband Bill sat in the exam room holding Bitsy as we placed a catheter and said goodbye to Itsy.

Photo by Wallace Chuck on Pexels.