By Dr. Becker
Daisy is a wonderful Golden Retriever I had the honor of meeting in May 2009 when she was already 13 years old!
Poor Daisy was suffering from arthritis, allergies, and lots of lumps and bumps on her body. She moved stiffly, her rear legs were weak, and her muscles were atrophying.
Dealing with Daisy’s Arthritis and Allergies
At my suggestion, Daisy’s wonderful mom, Val, started her on a rehab program to help strengthen her rear limbs and improve her range of motion. In addition to hydrotherapy, I started Daisy on Adequan injections, chiropractic care, and oral joint support to nourish remaining cartilage.
To deal with her allergic issues, we started Daisy on a novel protein raw food diet, which she loved. This helped to reduce the yeast growth on her skin, which made her less itchy. Daisy’s overall health and physical activity level improved and she had a wonderful year.
Daisy’s Liver and Kidney Enzymes are Elevated
In May 2010, I discovered that one of Daisy’s liver (GGT) and kidney (BUN) enzymes were elevated (page 1). We started her on milk thistle and chlorophyll supplements and rechecked the levels in a few months. Daisy’s kidney enzyme was back in the normal range, but her liver enzyme was still elevated (page 2), so we added a Chinese herb called Liver Happy and planned to recheck the level in a few months.
At that time, Val and I discussed the fact that there was quite possibly a serious underlying reason why Daisy’s liver enzymes were climbing, but that at her age, choosing to do anything invasive or radical would probably result in a reduction in the dog’s really good quality of life. So many of my clients go through this difficult realization process.
They know their aging pet’s blood work is abnormal… they know there could be degenerative issues, including organ failure or cancer… and they have to decide whether to choose “comfort care” – simply keeping their geriatric companion comfortable – or begin the sometimes grueling process of putting the animal through a series of expensive and stressful diagnostic tests.
Val and I had a very candid conversation at this point. I asked her this question: “If you’re considering more tests for Daisy, for example, a liver CT scan with biopsy, what will you do with the information you receive?” This is a very important question I ask every client who is faced with a similar situation. If they plan to use the information to schedule surgery for their pet, or pursue additional treatments like radiation or chemotherapy, then going ahead with costly, stressful tests is justified.
But if the owners don’t plan to submit their pet to additional aggressive treatments, then why spend the money? However, some people simply need a confirmed diagnosis before they can really begin to absorb the fact that their pet has an incurable disease.
Val decided if the underlying cause of Daisy’s elevated liver enzymes was a liver tumor, she would not pursue surgery or chemotherapy. And because Daisy was acting as she always did and showing no signs of illness or pain, Val decided to simply monitor her liver enzymes and provide supportive care.
Next Problem: MRSA
In February 2011, Daisy suffered a terrible outbreak of sores on her skin. We did a culture and learned she had MRSA (methicillin-resistant staphylococcus aureus) as well as pseudomonas (pages 3-5), two types of bacterial infections that are very resistant to antibiotics. I prescribed antimicrobial shampoos and oral medications, and when we re-cultured after six weeks of therapy, the infections had resolved (page 6). However, some normal bacteria was causing a few skin lesions, so we treated those with a cedar oil topical spray.
Daisy is Diagnosed with Serious Liver Problems and a Heart Murmur
Around the same time in February 2011, we rechecked Daisy’s liver enzymes again and discovered that now her ALT (another liver enzyme) was elevated in addition to her GGT (page 7). Her enzymes continued to increase in April (page 8), so I suggested a liver function test called a bile acids, which she failed (page 9).
Daisy was also found to have a heart murmur during that appointment, a new finding that Val decided not to pursue with additional diagnostics. We started Daisy on ubiquinol for heart support.
In December 2011, her liver enzymes were at an all-time high (page 10), and Val decided she really wanted to know why. She had an abdominal ultrasound completed at her local veterinarian, and sadly, our suspicions of a liver tumor were confirmed (page 11).
Daisy was 16 by this time and Val didn’t want to submit her to any invasive procedures. We did start her on several supplements to help her body recognize abnormal cell growth, including broccoli seed extracts, a concentrated source of glucoraphanin that supports healthy detoxification and is converted to isothiocyanate, which has been researched extensively in cancer therapy.
Daisy Develops a Huge Mass Behind an Elbow
In January 2012, Daisy’s ALT liver enzyme had improved (page 12), and it improved again at a recheck in the fall of 2012 (page 13). But around that same time, behind Daisy’s left elbow Val noticed a large lipoma (a fatty mass) beginning to grow and become firm. The mass continued to grow all winter and by January 2013, it was so big it prevented poor Daisy from standing up. It was huge.
Val and I had another heart-to-heart conversation about her pet. The only time I ever recommend removing a mass that has been diagnosed as benign is if it starts growing or changing. I only recommend removing a benign growth if a pet’s quality of life is impaired, and clearly Daisy’s mass met the criteria. Also, whenever benign lumps grow or change, I recommend re-aspirating them, because something is causing the changes – and some masses do progress from benign to malignant.
I talked with Val about what might be causing the mass to grow and the possibility of malignancy. Daisy’s age, heart murmur and liver tumor put her at increased risk to undergo anesthesia and surgery. There could also be a number of surgical and post-operative complications, including bleeding problems, blood pressure and heart complications, and a slow recovery period for a dog Daisy’s age.
We also discussed the rehabilitation that would be needed to get her mobile again, not to mention the emotional stress poor Daisy would have to endure.
The sad truth was obvious… Daisy had not been able to stand in over two months. She was becoming listless and less interactive. Val could see her fading. On Friday, January 25, 2013, Val and I discussed the fact that if Daisy didn’t have surgery to remove the mass, she would never walk again. Her quality of life was diminishing because she could no longer get around. Time was ticking by.
Needless to say, the thought of surgery on a dog Daisy’s age was overwhelming. There was the expense of it… and there were no guarantees. But Val decided she wanted to give Daisy the option to be able to walk again, understanding that euthanasia was the alternative to either no surgery, or a poor surgical outcome. Val scheduled Daisy’s surgery for Monday.
The Surgery is Successful, but Reveals Another Problem
The soft tissue surgeon who removed the mass said it was, thankfully, only attached to her body by a pedicle, which is a stalk that is easily removed. Daisy did have heart and blood pressure complications during surgery, but her gifted anesthesiologist managed her very well. The huge incision was closed with dozens of sutures. Val visited Daisy after her surgery and brought her home the next day.
Daisy began the long process of rehabilitation from both the surgery and from being immobile for several weeks prior. She was very weak, and her old muscles had further atrophied. She received hydrotherapy the day her sutures came out, as well as laser therapy, joint mobilization and massage.
Daisy’s tumor biopsy came back as a soft tissue sarcoma, possibly a hemangiosarcoma (page 14). There was a cancerous mass that had begun growing inside the lipoma that had been there for years.
We don’t know if Daisy’s tumor will regrow or metastasize where it was removed. We don’t know if Daisy’s liver tumor is bigger or smaller because Val has elected not to repeat the abdominal ultrasound. What we do know is that Daisy is up and walking again, and is happy to be able to spend time with Val outside. Val knows she’s been given some additional time with Daisy that she wouldn’t have had without considering surgery at a critical point.
There’s Much to Be Learned from Daisy’s Story
This wonderful story of Daisy and Val points out so many things, from my perspective. Most notably, that decisions we must make for our senior pets are rarely black and white… there are lots of grey zones. Your ability to accept the outcome – whatever the outcome may be – is something you must consider before making decisions in the grey zones.
Also important is the need to address changing lumps on a pet. Daisy has dozens of lipomas all over her body that have stayed the same size. But that one lump that grew and changed illustrates the need to address any mass that is changing or getting bigger. In the case of Daisy’s mass, there was cancer inside a large amount of fat that was causing the rapid growth. There isn’t a needle long enough to collect abnormal cells seven inches into the center of a lipoma that size. The only option was to remove the mass and have it biopsied. And certainly, removing a mass or performing any type of surgery on a geriatric dog with a heart and liver condition is risky.
It’s important to know there isn’t a right or wrong decision or answer in these cases. It’s about making a very personal decision about what you believe is best for your pet. In Daisy’s case, Val opted for surgery and the outcome was a success. The biopsy results yielded yet another diagnosis we’ve added to Daisy’s long list of health issues she appears to be managing quite well at her age.
Most importantly, Val’s desire to help Daisy walk again was achieved by opting for the surgery. Daisy’s resilient spirit and Val’s commitment to doing what she felt was in Daisy’s best interests makes this month’s Real Story very special. They are in a wonderful partnership together. Daisy is enjoying today, and Val sees each moment with her furry companion as a blessing she would not have had without making some very tough decisions.