Case File

I have known Zoe all her life. Her owner is a familiar client at the practice – one of the ‘regulars’ so to speak. The good news here is that such owners are dedicated to their pets, fully trusting of the vet-client relationship, and most importantly ACT QUICKLY if they spot a problem. I have no doubt, at all, that Zoe’s early and continued success has derived from the speed with which she was presented to us and the speed of attaining a diagnosis.

I saw Zoe at the end of August 2013. Her owner brought her in two days before, when she was diagnosed with a urinary tract infection. My colleague noted some enlargement of the lymph nodes in her neck at that time, and had noted their size and started treatment for the urinary signs, booking her in for a review within days. However when she re-presented she now had multiple lumps, present not only in the neck, but additionally in the shoulder areas and the backs of the knees, on both sides of her body. The lumps were firm to the touch, roughly spherical, and positioned deep to the skin surface.

We sampled the lumps there and then, by means of fine needle aspiration, a technique whereby we insert a sterile needle into the mass, and apply suction with a syringe to allow cells from the mass to enter the needle shaft. We can then transfer the cells to a glass slide, rapidly dry it, and submit it for examination by suitable clinical pathologists. We have a fantastic relationship with the superb clinical pathologists at the University of Bristol’s lab at Langford. There were various other tests performed at the same time. They turned around the information within hours and we were able to establish our diagnosis.

Zoe had large cell lymphoma, a form of cancer of the lymph system.

We started her on a course of chemotherapy. Chemotherapy for cancer can be a daunting proposition. Essentially it is a mix of different pharmaceutical therapies that come together to counteract the effect of the advancing tumour. Client liaison is paramount at this stage – it is all about demystifying the two big C words – Cancer and Chemotherapy; and also setting our levels of expectation. Are we expecting a cure? Are we going to achieve ‘remission’? How long will it take? Numerous other questions.

Although there are lots of varying protocols in the text books about cancer treatment options, the science behind these therapies can be limited and studies can be based on very small case numbers. The drugs that are out there in this field are also to be carefully considered. These are not pleasant drugs to be around if you do not have appropriate experience and facilities. There are implications for health concerns for the people around the patient too. For example disposal of the patient’s bodily waste has to be dealt with in a safe way so local contamination with the drugs is avoided. So we chose a protocol of drugs that we are familiar with and have used in the past, and we issued advice to the client regarding her safety and that of her family.

Zoe was started on 3 chemotherapy agents; one an everyday off the medical shelf steroid tablet, the second, also a tablet though much less commonplace, and finally she was to have an intravenous injection once a month. The latter is a drug which if it strays outside of the vein during an injection can damage the cells of the surrounding tissues so extreme care is taken when we administer this injection.

Secondary side effects can crop up with chemo drugs and they can have a dramatic effect on tissues such as the bone marrow. As this is where blood cells are made, it is important to get the dose right. We need to fight the cancer but we need to ensure we have the right numbers of blood cells circulating round her system too! So repeat haematology (blood cell) sampling was performed and we checked Zoe’s blood counts and adjusted her dosing, and the frequency of that dosing, accordingly. Some drugs can cause urinary bleeding so this was closely monitored too.

Zoe’s response was fantastic – she was reportedly running around, chasing a ball and generally acting like a puppy, all within the first week of her treatment. She continues to go from strength to strength. Her protocol seems to be suiting her well and by and large she has remained on a similar protocol since the start. We had some gastro-intestinal irritability issues to contend with and again she responded to supportive drugs in this regard very well. We now have a series of measures that we take around the various dates of the chemo cycle that keep everything working as it should in all departments. This is in essence fine-tuning. We have over time reduced some doses and increased some of the intervals between drugs, and between blood tests, and all appears to be well. At the time of writing we are 14 months down the line and Zoe is a fine and dandy 13 years of age.