FHO Recovery, Osteosarcoma and the Path Forward

I haven’t written since sharing the results of the Princess Pooch’s bone biopsy. I was in a kind of fog for awhile, and then I began doing what academics do: reading everything I could find on osteosarcoma in dogs. In addition to all that’s available on the internet–general veterinary publications and people sharing their own experiences with their dogs–I am fortunate to have access to a university library and all the wonderful databases that are available. I found a number of studies published in the journal of Veterinary & Comparative Oncology particularly informative.

After getting recommendations for veterinary oncologists from our regular vet, I called the folks at Integrative Veterinary Oncology. When the person I spoke to said their first available appointment was August 16th, my heart sank, but she then informed me that the doctor held times open for urgent cases and once she received the necessary records from our vet and the hospital where the Princess Pooch had surgery and had time to read them, I would get a call about finding an opening much sooner. True to her word, I received a call that evening. The doctor had received all the necessary records, taken the time to read them, and could see the Princess at 3:00 on Thursday. Whew!

By Wednesday I had read everything I could wrap my mind around, so I decided to make a list of the things that brought the Princess joy. I wanted to have this list when we spoke to the doctor so I could be clear about what “quality of life” meant for the Princess. Also, and anyone who knows me will not be surprised by this, I wrote up a list of questions and concerns. I did this so if I fell apart during our discussion with the vet, I could hopefully return my focus to what the Princess needed.

Thursday was a big day for us and for the Princess. First, we had an 8:30 am appointment with her surgeon for a post-op visit and to remove her staples. She’d been such a good dog about leaving her incision alone. I’d caught her licking it a few times, but as soon as I said “leave it,” she’d stop. I also was diligent about keeping an eye on her throughout the day, then putting the e-collar on her overnight. So that morning, Mr. Desert lifted her into the car and onto the bed we had there for her and off we went. She was excited to be in the car but was a good girl and mostly stayed in her bed which we appreciated because we didn’t have to worry about her slipping and sliding around.

Once we arrived at the hospital, we didn’t have to wait more than a few minutes before a tech took her back to remove the staples while we waited in an exam room. When the surgeon brought her back, he told us there were no staples to remove! We were both shocked; in fact, I think we both asked if he was sure. I knew the staples were there when I put the e-collar on her and tucked her into bed the night before, so where the hell did they go? Thankfully, her incision was healed and the surgeon was pleased with her progress, so we headed home. 20140181_10155343574666071_5728962414438881682_nHere’s a photo of her happy on her sofa for the first time since her surgery.

After we got home and got her settled, I decided to dig around in her bed: sure enough, I found five staples! I don’t know how many were in the incision, but she’d clearly pulled them out as we drove to the hospital. The little sneaker took advantage of the fact I wasn’t really paying attention anymore because we were on the way to get the things out! She’s one smart pup!

Oncology Consult
We arrived for our appointment a bit early, and the vet ended up running a bit late, so we spent some time in what is a lovely waiting area with big comfy sofas and chairs, cold bottles of water, coffee, a table with jigsaw puzzles, and a big glass door that opens into a room where the house kitties available for adoption. Yesterday there were 4 young adult tuxedo cats romping around, playing, and flying up and down the cat tree. We also met a couple of folks whose animals were being treated. One woman had an 8 year old cat who had been undergoing treatment for a year, and another woman said her dog had been undergoing treatment for 4 years and was now 11 years old. She couldn’t say enough about how fabulous Dr. Hershey is and how much she’d helped her dog. Her dog finished up his treatment before we went in to see the doctor, so we got to meet him. He’s a handsome grey and white pitbull. He ran up to his person with a big smile and a powerful tail wag. So by the time we were called back, we were feeling more hopeful.

We were taken to a huge room with more comfy sofas and easy chairs, and when the doctor came in she introduced herself, shook our hands then sat down on the floor to greet the Princess. She checked her out as she talked to us about her observations and what she’d learn from reading the records she’d received. She was very down to earth and clear, so much so I didn’t even open the notebook I’d brought!

In some ways, she said, the hip fracture was good because it drew attention to the bone which in turn helped them diagnosis the cancer early. She was clear that there is no cure for oseosarcoma, and that the goal of any treatment is to address pain and provide extended quality of life. She talked about recent studies, confirming what I’d been reading; answered my questions about the various drugs used to treat the cancer; and explained why she was recommending a particular treatment plan. Essentially there are 3 drugs used to treat oseosarcoma in dogs: Carboplatin, Doxorubicin and Cisplatin. Although Doxorubicin is the cheapest of the 3 drugs, it can cause irreversible injury to the heart, so it’s not a good choice. She explained that Cisplatin used to be the drug of choice because the cost of Carboplantin was prohibitive–often exceeding $1,000 per treatment while Cisplatin cost between $300 to $500 per treatment. The problem with Cisplatin, however, is that it is distributed widely into the liver and kidney and so requires tests on renal concentrating ability, azotemia and presence of abnormal numbers of granular casts in urinary sediment; because of the effects on the liver and kidney, a fluid diuresis pre treatment of several hours is required. Fortunately, the price of Carboplatin is no longer prohibitive, and studies show it is as effective if not a bit more so in treating Oseosarcoma. And, it doesn’t require fluid diuresis pre treatment; this is particularly important for the Princess Pooch because last year she was diagnosed with early renal disease.

So, the treatment plan is as follows: treatments of Carboplatin every 3 weeks for a total of 6 treatment and blood work and chest x-rays at specific times during this treatment to monitor her white cell count and to look for metastasis in the lungs. These are ways of assessing how effective the treatment is. In addition to being a board-certified veterinary oncologist, Dr. Hershey has also studied traditional Chinese veterinary medicine with Dr. Xie at the Chi Institute in Reddick, Florida and combines conventional Western therapies with acupuncture, herbal medicine, nutrition, ozone therapy, ultraviolet therapy and other therapies. Here a video of an interview with Dr. Hershey where she talks about this training.

The Princess Pooch had her first treatment yesterday afternoon, and other than some lethargy has had no side effects. The good news about chemotherapy and dogs is that side effects such as vomiting and diarrhea are rare, and if they do occur usually last a day or two.

In the meantime, her recovery from the FHO surgery is progressing well, and we’re hopeful this treatment plan will give her good quality of life for at least a year. Given her age, 12, that would be a wonderful gift.


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The Worst Possible News

Yesterday we received the worst possible news, something we knew was a possibility but were hoping wouldn’t be the case: the Princess Pooch has osteosarcoma, an extremely aggressive cancer that generally spreads rapidly to other parts of the dog’s body; in fact, the cancer has often metastasized by the time it is discovered. The National Canine Cancer Foundation reports that

Osteosarcoma is the most common primary bone tumor found in dogs. It accounts for up to 85% of all malignancies originating in the skeleton. It mostly occurs in middle aged to older dogs, with a median age of 7 years. Primary rib OS tends to occur in younger adult dogs with a median age of 4.5 to 5.4 years. Larger breeds have a high propensity for the disease. Dogs like Great Dane, Irish setter, Doberman pinscher, Rottweiler, German Shepherd and Golden Retriever are at greater risk of contracting osteosarcoma because of their size and weight. Intact males and females are also highly predisposed. Osteosarcoma can occur in any bone but the limbs account for 75%-85% of all affected bones and is called ‘appendicular osteosarcoma’. The remaining affects the axial skeleton comprising maxilla, mandible, spine, cranium, ribs, nasal cavity, paranasal sinuses and pelvis. Osteosarcoma of extraskeletal sites is rare, but primary OS has been reported in mammary tissue, sub-cutaneous tissue, spleen, bowel, liver, kidney, testicle, vagina, eye, gastric, ligament, synovium, meninges and adrenal gland. It develops deep within the bone and can become excruciatingly painful as it grows outward and the bone is destroyed from inside.

We knew this was a possibility when her fracture was diagnosed, and they used the bone removed during the surgery for the biopsy. The surgery, however, was necessary to address the fracture and, since the pre-surgery x-rays of her lungs were clear, this was the best first step. Often in the case of “appendicular osteosarcoma,” the limb where the cancer is located is amputated; we’re hoping the FHO surgery will stand in for the amputation and have decided we’re not going to put her through another surgery even if that’s not the case.


Princess Pooch, July 15, 2017

We’re devastated by this news but are doing our best to think about what’s best for the Princess. We’re waiting for an opportunity to talk with our own vet before moving forward, but our most likely next step will be to consult a veterinary oncologist. We’re lucky to live where there are a number of such specialists and facilities. A standard treatment for this cancer, in addition to amputation, is chemotherapy which apparently can present very few to no significant side effects in dogs. So, we’re open to that course of action if our vet and the oncologist believe it will help. From what I’ve learned, the surgery addresses the pain of the cancer, and in the Princess Pooch’s case the fracture, and the chemo provides additional time during which the dog doesn’t suffer the effects of the cancer.

According to the Princess Pooch’s surgeon and echoed by this canine osteosarcoma fact sheet, the prognosis is as follows:

  • without any sort of intervention, the average survival time is approximately two months after diagnosis;
  • if amputation is performed the average survival time is increased to six and a half months with 2% of patients alive after two years;
  • if amputation is combined with chemotherapy the average survival time is increased to one year with 20% of dogs still enjoying a good quality of life two years after surgery.

So, if she’s a good candidate for chemo and we can afford it, that appears at this time to be our best option. In the meantime, she’s doing really well and is more active and more like herself everyday. She’s putting that foot down when she walks more often than not now, and she’s back to being aggressive toward Reilly, spinning at the door, and her other routines.

For now we’ve decided to be cautiously optimistic and give her all the love and care we can until we know what’s best for her.

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FHO Recover, Day 5

The Princess Pooch continues to heal. She’s been up and around quite a bit today and is steadier on her feet with each passing day. Today she’s been putting her foot down while standing and sometimes while walking, but she’s yet to put any weight on it.

She’s back to indicating she needs to go outside when what she wants is a treat and not to pee. She’s never learned to scratch at the door or bark; instead, she peers around the recliner and stares, then gets excited when we ask if she “want to go potty.” I’m so happy p_pooch_sunto see her on her feet that I don’t care if she’s trying to trick me for a treat.  She’s also decided to catch some rays when she’s outside sometimes now. We don’t let her do so for long so she won’t burn, but I imagine the sun feels good.

I continue to move her hips in a “bicycle” motion in reps of 10 several times a day. This doesn’t seem to cause her any pain, but she stares at me with a look that says “what the hell are you doing?” Speaking of pain, we gave her the last of the pain pills last night, and she hasn’t shown any signs of pain.

She still shows little interest in her incision, and when she does on occasion, we just tell her to “leave it,” and she does. She hates the e-collar, but we continue to put it on her over night. She looks so sad when I put it on her; it breaks my heart.


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FHO Recovery, Day 4

Not much in the way of new developments today, but the Princess Pooch continues to get back into her routine. We moved from cold to warm compresses, and she doesn’t seem to enjoy those as much. And she looks longingly at the sofa and recliners where she likes to sleep but are now covered with chairs so she can’t get on them. She seems to have decided her original bed is the choice spot for now, but she does use the new bed on occasion.

We continue to try to stimulate her appetite: tonight’s dinner was rotisserie chicken with a bit of gravy mixed in with her regular food. She found a way to eat around most of her regular food, but we’re just happy she’s eating.

Here’s a photo of her on her favorite sofa from March 2017.

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FHO Recovery, Day 3

The Princess Pooch is even stronger today and is getting back to her routine. The pest guy was here today, and she was as wound up as she has been every time he’s been here. She didn’t jump on the sofa and spin and bark at him–we’ve blocked the sofa with a chair so she can’t get on it–but she did everything else in their usual routine.

She continues to put her left foot down in a normal position when standing, but she has yet to put any weight on it. We were told she probably wouldn’t for at least a week, so we’re not concerned. She is putting it in the more usual position when she squats to pee, and she even managed a bit of a poop today–not much since she hasn’t been eating much.

Speaking of eating, tonight we got her a carne asada burro of her own, and she chowed down with tail wagging enthusiasm. It was good to see her eat and enjoy a meal. She loves carne asada burros, and I usually share mine with her. I think she knew getting one of her own was a big treat.

We’ve moved her pain medicine schedule from every 6, to every 8 and now to every 12 hours, and she seems to be doing well. She’s now resting on either hip as her mood dictates, so that his is clearly no longer bothering her.

So far I’ve just been walking her around inside the house because it is brutally hot outside; it’s supposed to cool down to just above 100° by Sunday, so I hope we can begin walking outside then.

new_ecollarFinally, her inflatable e-collar arrived today, and she seems to hate it less than the big plastic one. She hasn’t tried to lick or go after her incision at all today, but we’ll put it on overnight just to be sure she can’t get at it if it starts to itch.

I am very pleased with her progress. Even though she’s an active 12-yr old, I was concerned this surgery might take a lot out of her; I am happy to see it hasn’t.

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FHO Recovery Day 2

Today the Princess Pooch was much more steady on her feet–3 of them–and moved around quite a bit more than she did after coming home from the hospital yesterday. She still isn’t eating much, but I gather that’s not unusual.

On a few of her trips outside, she put all 4 feet on the ground. She didn’t put any weight the leg where she had surgery, but she did put that foot on the ground in a normal fashion–the first time she’s done that since breaking her hip on Saturday, July 1st.

Although she’s not licking or paying much attention to her incision, we’re still putting the e-collar on overnight. You can see from the photo below how happy that makes her.


The inflatable one we ordered is scheduled for delivery tomorrow.

Thus far I am pleased with her progress. Tomorrow’s goal is to whet her appetite.

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Summer of Injuries

It seems breaking my elbow and wrist were just the beginning of our summer woes.

A week ago, sound asleep then awakened by the door bell, the Princess Pooch went flying toward the door and her left back leg slipped out behind her. The result was a broken hip. She had FHO surgery on Friday, and we brought her home early this morning.

According to Topdog, Femoral head osteotomy,

also referred to as a femoral head ostectomy or FHO, is the surgical removal of the head and neck of the femur. In simpler terms, it is the removal of the “ball” part of the ball-and-socket that makes up the hip joint. This way, the bones of the joint are no longer in contact, which eliminates the pain that is caused by the abnormal contact of the bones . . . . Once the femoral head and neck are removed, the surrounding muscles and developing scar tissue work to support the area, and act as a false joint. This means that now when the limb is moved, the forces are transferred to the pelvis rather than the leg itself. The FHO Surgery is a fairly simple procedure in that minimal equipment is required, and no implants are needed. The procedure causes the leg to be slightly shorter than the unaffected leg, although amazingly, most dogs return to close to normal activity after the surgery.

princess_pooch_homecomingSo far, the Princess seems to be doing pretty well. Since we had some lead time on the surgery, we got her a new bed with bolsters on three sides rather than all the way around so she has a flat entrance and some non-skid carpet runners so she has better traction on the tile, and these seem to be making getting in and out of bed and around a bit easier for her.

She’s been up and about much of the day, drinking lots of water and heading outside to pee. She’s even had a bit to eat, so we’re feeling pretty good about her progress so far. She’s pretty much leaving her incision alone after having to wear an e-collar for about half an hour after trying to lick the area. We ordered her an inflatable e-collar that will arrive Monday; at least it will be more comfortable if she has to wear it.

For now, we’re putting an ice pack on her incision for 10 minutes and will continue to do so for the next three days; then we’ll move to a warm compress for 10 minutes three times a day for three days after that.

She’s restricted from running, jumping, playing, using stairs or jumping onto sofas for the next 2-4 weeks. Since she’s 12 and we don’t have stairs, our major concern will be keeping her off of the furniture and from playing–she loves to fetch and chase her tail even at her advanced age.

She can hang out in the house as long as one of us is here to keep an eye on her to ensure she’s not doing any of the above activities, and otherwise we’ll restrict her to a small space and do the same each night. We’ll take her on short walks of 10 minutes or so 3 times a day for the next two weeks, probably early morning and late in the evening and around the house mid-day since it’s so bloody hot here. Then, when her staples are removed in 2 weeks, we’ll begin to take her swimming in addition to taking her on increasingly longer walks. By week 4, if all goes well, she’ll be able to return to her normal level of activity.  Oh, and we’ll do some range of motion work on her back legs for the next two weeks as well. Hopefully rehabbing my own broken elbow has prepared me for this task.

For now, she’s on some pain medication and pepcid in addition to her Prozac for anxiety and Galliprant for arthritis pain.

I plan to document her recovery in the hope that her experience might help other folks whose pup is facing this process.

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