Soooo, pull up a chair and grab your beverage of choice while I tell you the tail of Codie Rae's epic battle against the Veterinary Industrial Complex (VIC)! 

Two days before we were scheduled to help our beloved recreation director, Smokey B, cross the Bridge Codie Rae yawned and I saw....a lump in her mouth. JHC I thought to myself, now what?!? So off we went to our regular vet, Dr. Dunn, who said hmmm, it could be any number of things--lets do an excisional biopsy and find out. So we did just that. Dr. Dunn took some xrays, which showed no bone involvement, whacked that lump down to size , and sent it off to be biopsied. Of COURSE the biopsy came back inconclusive--it was either osteosarcoma or an atypical ameloblastoma and the pathologist was leaning towards ameloblastoma after getting a second opinion. The pathologist recommended additional staining to further dial in a diagnosis.

By this time it was two weeks after the biopsy surgery and the damn thing had already grown back to equal its pre-surgery size. Dr. Dunn recommended we consult with an oncologist before doing further pathology because she felt the treatment would be the same no matter the diagnosis. She suggested that the lump could be removed again and a rim excision (removal of the tumor, tooth, and a little bone right around the tooth cavity) or something close to that could be performed successfully.

So, feeling a little panicked since the lump seemed really aggressive, we made an appointment with Dr. Andres, an oncologist at a local VCA hospital (VCA/BAVS in San Leandro CA in case you want to avoid them like the plague--BAVS used to be great until they were subsumed by VCA and the VIC!!). We had many misgivings because this was the same hospital that insisted Travis Ray needed a TPLO for an ACL tear that might or might not exist (xrays did not really show anything--so he did NOT have a TPLO and recovered great with a little rest and rehab). Our other option was UC Davis but we knew it would take weeks to get in there and the lump seemed to be growing a little larger every day! So VCA it was. Dr. Andres told us the only possible treatment was a partial hemimandibulectomy (removal of part of the jaw). Thinking back to Travis and his soft tissue sarcoma I asked about intralesional therapy (administering chemo injections directly to the tumor/surrounding area) and Dr. Andres said flatly that would not work because the tumor had likely invaded the bone no matter what it was and intralesional injections could not be administered to bone. We told her look--this is a 13.5 yo tripawd dog who is already having significant mobility issues--we honestly don't expect her to be around a year from now. Yes, removing part of her jaw would be the gold standard treatment but would have a potentially difficult recovery time and we just didn't want to put her through all that--if she were younger and in better shape maybe.  According to her there was no other option. We agreed to do thoracic xrays there to see if there was anything showing up in Codie's lungs (nothing but they showed she has major arthritis in her spine), and some bloodwork, and we were on our way, off to do a sh*t ton more research. 

One of the first things I ran across in my further research was a study by Dr. Kelly of Veterinary Cancer Care about using intralesional therapy to treat.....ameloblastomas. And then I found another study on using intralesional therapy to treat bone mets--they drilled holes into the bone and administered chemo that way). Both studies, admittedly with small patient numbers, were wildly successful. This was the treatment we wanted for Codie Rae. But could we find someone to do it? Hell no. We called a doggie dental specialist--we don't do that, we would do a hemimandibulectomy. We called UC Davis, thinking since they did intralesional chemo for Travis they might do this. No, we don't do that, we would do a hemimandibulectomy. WTF?? You would think a teaching hospital would be all about cutting edge, experimental treatments but nope. Why on earth would a vet not want to to do the least invasive possible treatment on an aged tripawd with mobility issues? 

So we called Dr. Kelly in Santa Fe. She helped us figure out what to do for Travis and here she was treating oral tumors with intralesional chemo. Seemed like a no brainer to consult with her. Dr. Kelly told us she had graduated from simply doing intralesional chemo to doing electrochemotherapy. Uhhh, what?? According to Dr. Kelly's website:

[electrochemotherapy ] allows chemotherapy drugs to better reach their intracellular target; studies have shown increases in cytotoxic activity up to 1,000-fold. The process includes injecting a chemotherapeutic agent followed by local electrical pulses. ECT can be used to treat local disease and as an adjuvant to surgery. For some cancer types, ECT is a great alternative option to radiation as it is typically less expensive, requires fewer anesthetic procedures, and has few long-term side effects. 

Well this sounded just about perfect to us. Less expensive? Yes, but more importantly--fewer anesthetic procedures and few long term side effects sounded ideal. Dr. Kelly said that one could do a single ECT and in some cases the tumor never came back. In other cases you might have to treat more than once but it would be periodic, like maybe once or twice a year. Dr. Kelly suggested a clinic to try in San Francisco that was supposed to do ECT but they didn't. That clinic referred us elsewhere but they didn't do ECT either. But we finally found a local clinic that did. Woohoo! Right?? 

So we packed Codie Rae off to Sage in Dublin. We went in knowing what we wanted but had to listen to the oncologist there tell us well you really should do a hemimandibulectomy. And oh, before you do that you should consult with our internal medicine people because her kidney values are a bit high. And then you should do a CT with contrast and then.....We said, thanks but no thanks, we would like to proceed with the ECT thank you very much. So they obligingly gave CR an ECT treatment that very day. Yay!

Contrary to what Dr. Kelly had told us, Sage's protocol was to do three treatments 2 weeks apart. We asked about a longer time period between treatments, having also read about taking up to four weeks before a second treatment if warranted. Well, this is what we do they said. So we made a 2nd appointment with the understanding that we would assess the effects of the first treatment before actually going through with a second treatment in two weeks. Well, the first treatment seemed to stop the tumor in its tracks. It may have actually gotten smaller but it definitely quit growing larger. We also heard from Dr. Kelly via Rene (who had just interviewed her) that she often would pull the tooth where the tumor was in order to better access the entire affected area with the ECT. Made sense to us!  

We decided to go ahead and get the further biopsy staining done before the second treatment and the results came back as atypical osteosarcoma. Ugh. 

So I started emailing Dr. Tu at Sage with the biopsy result, questions about hypothetical tooth pulling, criteria for further ECT treatments etc. Seems like every answer I got spawned more questions. And if we wanted the tooth pulled then we would have to consult with one of their surgeons (SOP I know, but dang, how many consults do you have to pay for to take care of one issue??). Oh, and what about getting that CT done?? In the meantime, Codie Rae yawned one day and I saw ANOTHER lump!! This one just behind her top front teeth and it was bigger than the first! Of course I let Dr. Tu know and had more questions. Now a hemimandibulectomy seemed really out of the question since both her upper and lower jaws were involved. When Dr. Tu told me if I wanted to ask her any more questions I would have to pay for another consult with her I blew a gasket. WTFFFF? I called Sage and asked them to send me Codie's records. They were not getting anymore of our money. HELL no!!! 

Wait!! It gets better!! We got the records and took a look. There were photos of her mouth showing the first tumor. They ALSO clearly showed the SECOND TUMOR!! And NO ONE AT SAGE NOTICED?????? Would not any self respecting vet take a thorough look in her mouth for additional tumors once they had her knocked out??? So our decision to jump ship was totally validated right then and there.

Sooooo, Ralph and Codie Rae set off on their epic road trip to New Mexico to see Dr. Kelly. OMD! We are so happy we went! Codie Rae had two tumors removed, three teeth pulled, and ECT administered. She flew through recovery from the surgery and was on the road back home the second day after surgery. We're a month out and so far so good. The inside of her mouth is still a little scary looking but appears to be healing well with no signs of infection or bone exposure (the main potential side effects). And best of all, no sign of anything growing back (you will recall after the excisional biopsy the first tumor was back in less than two weeks). Dr. Kelly sent samples from both tumors for biopsy. The first was validated as osteo, the second was gingival hyperplasia. So, the treatment on the second was overkill but given the circumstances at the time seemed warranted. Codie's biggest issue right now is....as predicted....her mobility, dang it. So, not having hemorrhaged enough money for this dog, we have an appointment with a pain management specialist coming up. 

Moral(s) of this overly long story? Listen to your gut instinct--after we talked to Dr. Kelly the first time about Codie we seriously weighed going to NM but that seemed ridiculous when there was someone who could do ECT locally. Advocate for your pet--if you don't like what your vet is proposing do your research, and push back, seek a second opinion, look for vets thinking outside the box like Dr. Kelly! And....take care of your pet's dental hygiene on a regular basis!! No slacking!! Benign oral masses can become malignant but most masses can be avoided with proper dental care! 

xoxo,

Martha, Codie Rae, and the Oaktown Pack