OK, so a little back story first. A couple months ago I noticed a lump on Travis' right elbow. It was about 1 inch in diameter, squishy and did not seem to be attached. This was right after we had him into the vet for an anal gland infection so, suffering from vet fatigue, we thought oh, its just a lipoma, and went on with our lives. A month or so later it had changed, it was not any larger but seemed more apparent and had grown harder to the touch. Time to go back to the vet! 

One fine needle aspirate later, the suspicion was that it was a soft tissue sarcoma (STS). So we headed off to UC Davis for an oncology consult. There was no question of doing a biopsy (pretty much just as invasive as full removal), we just went straight to getting that thing off our sweet boy! Pre-op xrays were clear (yay!) and a pre-op abdominal ultrasound was clear (triple-quadruple yay!) (we did this bc his physical exam showed he had an enlarged spleen, which I did not know is relatively common in GSDs). Given where the tumor was they warned us to expect dirty margins. Travis rocked his surgery and recovery, he is strong and doing really well, and so here we are, trying to decide what the next step is. 

At our oncology follow up we learned that TR's tumor was a grade 2, likely fibrosarcoma. We were hoping for grade 1, which most of these tumors are, but hey, I am just thankful its not a grade 3. So, its intermediate grade with "close" or "narrow" margins (which means they got it all.....maybe...the margins are only 1mm). Davis presented us with a couple options (cost is a factor but we would bankrupt ourselves if we thought it was the only way, I'm including cost for informational purposes but bear in mind these are costs at a teaching hospital). Quotes are from our post-op oncology visit summary.

1. "The most aggressive and most studied option is to perform definitive radiation therapy, which is daily radiation doses Monday through Friday for 3-4 weeks. We expect with this option to achieve local disease control in 95% of patients at 1 year, 85% at 3 years, and 75% at 5 years (these are studies for dogs with incompletely excised tumors - meaning there are cancer cells left behind). Therefore, there is a chance that Travis Ray could do even better with a narrowly excised mass. The cost of definitive radiation therapy is approximately $6200-6500." 

At UC Davis the radiation protocol for STS is 16 treatments over 4 weeks, five days/wk, and the dog must be sedated during each treatment. We live about 1.5 hrs (with no traffic) from Davis. Travis stresses really bad when he goes to the vet. They say dogs tolerate radiation and chemo better than we do but this seems really brutal, even for a dog that is otherwise fit. We are really not considering this option because TR's tumor was not grade 3 and we think it would be awfully hard on him (not to mention Ralph--it would basically be a full time job for him to take Travis up there every day). If the tumor was a grade 3 we would definitely consider this option though. 

2. "The least aggressive option is to monitor the site for recurrence without any additional adjuvant treatment. If/ when recurrence occurs, then we could treat with another marginal surgery. Expected recurrence rates without any additional treatment fall somewhere between 10-40+%. It is difficult to predict if Travis Ray's tumor will recur, as technically his surgery was complete, but with the cancer cells so close to the edge, it is concerning that there may still be some cells left behind."  

A grade 2 STS, especially when located where TR's is, apparently has a relatively low rate of metastasis (yay!). Chances of recurrence with no follow up are higher than we would like though. While his margins were clean they are so narrow (1mm vs the 3cm margins that would pretty much guarantee no recurrence) there could still be cancer cells around the surgery site. If it did recur we could potentially do another surgery, as long as we caught it early when it was still small. I emailed TR's surgeon and she said they typically remove the scar tissue from the original surgery as well as the new mass so that could be difficult given there is not much excess skin left at his elbow. 

3. "A "middle of the road" option to try and address the microscopic disease left behind is a treatment utilizing chemotherapy infusions in and around the scar. These would be performed under heavy sedation to ensure we keep Travis Ray as comfortable as possible and minimize exposure to the team doing the infusions. This has not been officially published but was presented as an option a veterinary cancer conference. The median survival time reported with this treatment (meaning 50% of patients do better and 50% do worse) was >1,000 days. There was a recurrence in 27% of patients but this was significantly less than the reported recurrence rate in patients that had surgery alone. Again, these were dogs with incompletely resected tumors with a much higher risk of recurrence than those with narrowly resected tumors like Travis Ray. With this option, we would plan to do chemotherapy infusions around the scar once weekly for 6 total doses. However, the schedule may have to be flexible and allow for dose delays to possibly every 2 or 3 weeks if there are any local reactions or irritation. The most common reported side effects included mild skin toxicity that required dose delays. With systemic chemotherapy (when injected into a vein), we expect ~15-20% of our patients to experience side effects, which includes bone marrow suppression (reduced white blood cells or platelets) and GI toxicity (vomiting, diarrhea, inappetence). While these could also be possibilities with the regional chemotherapy infusion, I imagine they would occur less commonly compared to systemic administration. We would still plan to send you home with anti-nausea and anti-diarrheal medications, as well as check blood work at the one week mark before giving another infusion. The charges for each visit would be ~$400-600."

We are looking hard at this option right now. I need to see if I can find a copy of the presentation on this treatment. There are no published studies yet but apparently the results are promising. Davis has only tried it with one dog (!) but they said she is doing well so far. The drug is called 5-fluorouracil (5-FU). It is tempting to try this but I would sure like some more info! 

4. "Another option is "metronomic" chemotherapy, which is low dose, oral chemotherapy given at home every day. There are some studies which show that this may slow down or delay recurrence rates for incompletely resected soft tissue sarcomas. The cost of this medication would be approximately $150-200 per month, and Travis would need recheck bloodwork monthly which is approximately $200-300."

Metronomics is the other option we are seriously considering right now. Cost is comparable to that of the injected chemo option but would last much longer. It is my understanding that you do metronomics as long as the dog will tolerate. Is that correct? So if we went with this option would we really need to continue it the rest of Travis' life? 

So thats kinda where we are at right now. All input welcome!!!! I have been a part of the Tripawd Nation for going on 10 years, give or take a few, but have not been dealing with cancer with any of my current dogs until now (my heartdog Rosa died of hemangiosarcoma in 2005). I am so grateful to be able to turn to you guys for your experience and support! 

xoxo,

Martha, Travis Ray, and the Oaktown Pack

P.S. Travis Ray would love it if you visited his blog for HIS perspective on this whole thing!