Hi Pam,

Isabelle is six months out from her amputation (OSA), without clinical evidence of mets. She was imaged from head to toe last week.. Her last abdominal US was last month, (she has chronic, unchanged splenomegaly w/a few hypoechoic nodules unchanged since her first US 4 years ago) when she had a gr 2 (MI: 0/10hpf) MST resected from her remaining rear leg. The excision was complete with adequate margins. She did not have chemo following her amputation. Her other significant issue is L-S spine arthritis, very successfully managed with acupuncture, aggressive underwater treadmill, chiro, cold laser, massage, & monitored activity. She has been on Metacam for a little over a year. I'm not sure she needs it everyday anymore because she's fine most mornings before her dose. I haven't changed anything, partly because I don't want to mess with success & partly because there may be some angiogenic benefit. Otherwise, she has a chronically elevated ALT, max over the years 356. A liver biopsy more than 3 years ago, showed nothing significant. Her PLTs & WBCs have always been at the low end, or slightly below normal, most recently 150K/4.9. She has a hx of heartworm disease & Rocky Mountain Spotted Fever.

I decided at the onset, if she were in this position at six months, I would explore metronomics and decide if there was any benefit to her. Her quality of life is excellent and compromising that, isn't an option. I also have to consider, she is about 13.

I consulted an oncologist today. His recommendation was low end dosing of Palladia M-W-F/low dose cyclophosphamide T/Th/Sat. Leaving her on Metacam, rather than switching to piroxicam. His opinion was the more toxic side effect of Palladia have been minimized with dose reduction. She can stay on all of her supplements/homeopathics: fish oil, Hoxsey, SAT, Marin, SAM-e, Vit a, CoQ10, ester-c, apis-mel, arnica. He is not completely against her staying on a raw diet, provided she continues to eat Stella & Chewy's.

I'm sorting through the risk-benefit now & wonder if you would offer your thoughts. The human data on all the metronomics is mixed, but particularly with the VEGFR2. The animal models are promising, but the reality is looking more like VEGFR unrelated pathways are negating the benefit. Of course, life expectancy is different and humans are more willing to sacrifice quality for time. I realize any data without previous IV chemo is anecdotal, so I'm likely looking for unavailable information. I'm particularly worried about muscle wasting, as well as general fatigue, GI complications. Inactivity for Isabelle would be severely debilitating because of her arthritis.

Isabelle & I will live with this decision & I don't believe I will pursue further treatment, so I want to carefully consider the choices.

Thanks so much,

Cynthia

Thanks, I did review all them…10 times, at least! I think I'm most concerned about the Palladia & am just not convinced it's worth the risk.

Thanks Pam,

I really appreciate your input. I think I'm OK with the Cytoxan, but the Palladia makes me very nervous, even though the dose would be low. The oncologist did offer other plans, but was strongly in favor of this one. Isabelle was on artemisinin for about a month, but had severe reflux that was unrelieved w/H2blockers, so I stopped it. I'm having a hard time justifying the risk to her quality of life.

Thanks so much,

Cynthia