Canine Lymphoma: Risk Factors, Symptoms, Diagnosis, and Treatment
Lymph nodes are positioned all through the within and exterior of the physique. Those on the surface (indicated above) are referred to as peripheral lymph nodes and may be palpated. Normal lymph nodes are small bean-shaped constructions that you simply often don’t really feel or barely really feel when petting your dog. The dimension of lymph nodes is dependent upon the scale and sort of dog; basically, they need to sometimes be lower than ½ inch in dimension. The most typical preliminary symptom of multicentric lymphoma in dogs is agency, enlarged, non-painful lymph nodes. A lymph node affected by lymphoma will really feel like a tough, rubbery lump beneath your dog’s pores and skin.
Lymphoma accounts for 7 to 24% of all canine cancers and roughly 85% of all of the blood-based malignancies that happen, making it one of the vital frequent cancers present in dogs. Lymphoma – additionally known as lymphosarcoma – is just not a singular sort of most cancers however somewhat a class of systemic cancers with over 30 described sorts.
Lymphoma happens when there’s a genetic mutation or collection of mutations inside a lymphocyte that causes the cells to develop abnormally and change into malignant, in the end affecting organs and physique capabilities. Lymphocytes are the infection-fighting white blood cells of the immune system and are produced by the lymphoid stem cells within the bone marrow and lymphoid tissue within the bowel. Their function is to forestall the unfold of illness, to offer long run immunity in opposition to viruses, assist in wound therapeutic, and present surveillance in opposition to tumors.
Lymphocytes are a part of the lymphatic system – a community of tissues and organs that assist rid the physique of poisons, waste, and different undesirable supplies. The main perform of the lymphatic system is to move lymph, a fluid containing lymphocytes, all through the physique. Unfortunately, cancerous lymphocytes flow into via the physique simply as the conventional lymphocytes do.
Although lymphoma can have an effect on nearly any organ within the physique, it mostly turns into evident in organs that perform as a part of the immune system – the places the place lymphocytes are present in excessive concentrations – such because the lymph nodes, spleen, thymus, and bone marrow. Swelling happens when the numbers of cancerous lymphocytes improve; one of the vital frequent websites of accumulation are within the lymph nodes themselves, leading to an elevated dimension of those constructions.
Canine lymphomas are related in some ways to the non-Hodgkin’s lymphomas (NHL) which happen in people, although dogs are two to 5 occasions extra probably than individuals to develop lymphoma. The two ailments are so related that nearly the identical chemotherapy protocols are used to deal with each, with related responses reported. NHL has been featured just lately within the high-profile circumstances involving people who developed non-Hodgkin’s lymphoma after utilizing the weed killer glyphosate (most extremely acknowledged beneath its best-selling model identify, Roundup).
Because of its similarity to the human type, canine lymphoma is likely one of the finest understood and well-researched cancers in dogs. It is likely one of the few cancers that may have lengthy durations of remission, even lasting years, and though uncommon, full remission has been recognized to happen.
The reason behind canine lymphoma is just not recognized. It is suspected that the trigger could also be multifactorial. In an effort to find out what elements have an effect on the potential for creating the illness, researchers are trying on the function of environmental parts similar to publicity to paints, solvents, pesticides, herbicides, and pesticides; publicity to radiation or electromagnetic fields; the affect of viruses, micro organism, and immunosuppression; and genetics and chromosomal elements (modifications within the regular construction of chromosomes has been reported). It is assumed that dogs dwelling in industrial areas may very well be at the next threat for creating lymphoma.
BREED DISPOSITION AND RISK FACTORS
Although the direct reason behind lymphoma can’t be recognized, research have discovered that there are specific breeds which might be at increased threat of creating the illness. The mostly affected breed is the Golden Retriever, equally represented by B-cell and T-cell lymphomas (see beneath).
Other breeds exhibiting elevated incidence embrace the Airedale, Basset Hound, Beagle, Boxer, Bulldog, Bull Mastiff, Chow Chow, German Shepherd Dog, Poodle, Rottweiler, Saint Bernard, and Scottish Terrier. Dachshunds and Pomeranians have been reported as having a decreased threat of creating canine lymphoma.
Lymphoma can have an effect on dogs of any breed or age, but it surely usually impacts middle-aged or older dogs (with a median age of 6 to 9 years). There has been no gender predisposition famous, however there are reviews that spayed females could have a greater prognosis.
A current massive scale examine printed within the Journal of Internal Veterinary Medicine (Volume 32, Issue 6, November/December 2018) and performed by the University of Sydney School of Veterinary Science in Australia, examined veterinary data for breed, gender, and neuter standing as threat elements for creating lymphoma. Quite a few breeds have been noticed to be in danger that had not been beforehand recognized as being in that class.
The examine additionally demonstrated the alternative: Several breeds beforehand documented to have an elevated threat of lymphoma failed to point out an elevated threat. Additionally, the examine discovered males had the next threat total throughout breeds, as did each males and females that had been neutered or spayed. Mixed breeds usually had a decreased threat in comparison with purebred dogs. While these findings could also be inconsistent with different usually accepted threat elements, the examine states, “These three factors need to be considered when evaluating lymphoma risk and can be used to plan studies to identify the underlying etiology of these diseases.”
LYMPHOMA TYPES AND SYMPTOMS
Typically, a dog who will get recognized with lymphoma will initially be taken to a veterinarian as a result of a number of lumps have been discovered beneath the neck, across the shoulders, or behind the knee. These lumps become swollen lymph nodes. The majority of dogs (60 to 80%) don’t present some other signs and usually really feel nicely on the time of prognosis.
Advanced signs rely on the kind of lymphoma and the stage and can embrace swelling/edema of the extremities and face (happens when swollen lymph nodes blocks drainage), lack of urge for food, weight reduction, lethargy, extreme thirst and urination, rashes, and different pores and skin circumstances. Breathing or digestive points could also be current if the lymph nodes within the chest or stomach are affected.
Because the lymphatic system aids in preventing an infection, fevers are sometimes one of many first indicators of the illness. Additionally, since lymphoma impacts and weakens the immune system, dogs could also be extra vulnerable to sicknesses, which may result in sophisticated well being points. Lymphoma itself, nonetheless, is just not regarded as painful to dogs.
Lymphoma can happen anyplace within the physique the place lymph tissue resides and is classed by the anatomic space affected. The 4 most typical sorts are multicentric, alimentary, mediastinal, and extranodal. Each sort has its personal set of traits that decide the medical indicators and signs, charge of development, remedy choices, and prognosis. Furthermore, there are greater than 30 totally different subtypes of canine lymphoma.
Multicentric Lymphoma. This is probably the most predominant sort of lymphoma, accounting for 80 to 85% of all canine circumstances. It is much like non-Hodgkin’s lymphoma in people. The first noticeable signal of this kind is often enlargement of the lymph nodes within the dog’s neck, chest, or behind the knees, typically as much as 10 occasions their regular dimension, with the affected person not exhibiting some other distinctive indicators of sickness.
Multicentric lymphoma tends to have a speedy onset and impacts the exterior lymph nodes and immune system; involvement of the spleen, liver, and bone marrow are additionally frequent. The illness could or could not contain different organs on the time of prognosis, however it will definitely tends to infiltrate different organs, inflicting dysfunction and ultimately resulting in organ failure.
As it progresses, extra signs together with lethargy, weak spot, dehydration, inappetence, weight reduction, issue respiratory, fever, anemia, sepsis, and melancholy could also be noticed. This type may also metastasize into central nervous system (CNS) lymphoma in later levels, which may trigger seizures and/or paralysis.
Alimentary (Gastrointestinal) Lymphoma. This is the second most prevalent type of canine lymphoma, nonetheless it’s a lot much less frequent, accounting for under about 10% of lymphoma circumstances.
Because it’s within the digestive tract, it’s harder to diagnose than the multicentric type. It is reported to be extra frequent in male dogs than females. This sort types intestinal lesions, sometimes ensuing within the manifestation of gastrointestinal-related indicators, together with extreme urinating or thirst, anorexia, belly ache, vomiting, diarrhea (darkish in coloration), and weight reduction attributable to malabsorption and maldigestion of vitamins.
The illness impacts the small or massive gut, and it has the potential to limit or block the passage of the bowels, leading to severe and sophisticated well being dangers or fatality.
Mediastinal Lymphoma. This is the third most typical sort of canine lymphoma, however it’s nonetheless a reasonably uncommon type. Malignant lesions develop within the lymphoid tissues of a dog’s chest, primarily across the cardiothoracic area. This type is characterised by enlargement of the mediastinal lymph nodes and/or the thymus. The thymus serves because the central organ for maturing T lymphocytes; consequently, many mediastinal lymphomas are a malignancy of T lymphocytes.
The signs of mediastinal lymphoma are typically pretty obvious, involving enlargement of the cranial mediastinal lymph nodes, thymus, or each. It may also trigger swelling and irregular development of the top, neck, and entrance legs.
Dogs manifesting with this illness could have respiratory issues, similar to issue respiratory or coughing and swelling of the entrance legs or face. Increased thirst leading to elevated urination may also happen; if it does, hypercalcemia (life-threatening metabolic dysfunction) must be examined for because it seen in 40% of dogs with mediastinal lymphoma.
Extranodal Lymphoma. This is the rarest type of canine lymphoma. “Extranodal” refers to the way it manifests in a location within the physique aside from within the lymph nodes. Organs sometimes affected by this sort embrace eyes, kidneys, lungs, pores and skin (cutaneous lymphoma), and central nervous system; different areas that may be invaded embrace the mammary tissue, liver, bones, and mouth.
Symptoms of extranodal lymphoma will fluctuate significantly relying on which organ is impacted; for instance, blindness can happen if the illness is within the eyes; renal failure if within the kidneys, seizures if within the central nervous system, bone fractures if within the bones, and respiratory points if within the lungs.
The most typical type of extranodal lymphoma is cutaneous (pores and skin) lymphoma, which is categorized as both epitheliotropic (malignancy of T lymphocytes) or nonepitheliotropic (malignancy of B lymphocytes.) In the early levels, it often presents as a pores and skin rash with dry, purple, itchy bumps or solitary or generalized scaly lesions and is pretty noticeable because the situation causes discomfort.
Because of this presentation, it’s typically initially mistaken for allergy symptoms or fungal infections. As it turns into extra extreme, the pores and skin will change into redder, thickened, ulcerated, and may ooze fluids; massive lots or tumors can develop. Cutaneous lymphoma may also have an effect on the oral cavity inflicting ulcers, lesions, and nodules on the gums, lips, and roof of the mouth (typically mistaken at first as periodontal illness or gingivitis).
Within every of the 4 sorts described above, the illness may be categorized additional into subtypes. There are greater than 30 totally different histologic subtypes of canine lymphoma recognized; some researchers theorize that there could also be lots of of subtypes, primarily based on molecular evaluation of markers, classifications, and subtypes of lymphocytes.
At the second, additional data concerning the varied subtypes would in all probability not end in vital modifications in remedy protocols. In the long run, focused therapies for subtypes might result in simpler therapies and improved prognosis.
The two main and particularly related subtypes are B-cell lymphoma and T-cell lymphoma. Approximately 60 to 80% of lymphoma circumstances are of the B-cell lymphoma subtype, which is a constructive predictor; dogs with B-cell lymphoma have a tendency to reply positively to remedy with the next charge of full remission, longer remission occasions, and elevated survival occasions. T-cell lymphoma constitutes about 10 to 40% of lymphoma circumstances and has a detrimental predictive worth primarily based on not responding as nicely to remedy and for being at the next threat for hypercalcemia.
DIAGNOSING CANINE LYMPHOMA
Early detection and remedy are important to making sure the absolute best end result for lymphoma circumstances. Because dogs usually really feel nicely and there are sometimes solely swollen lymph nodes (with no ache exhibited) as a symptom, catching the illness early can typically be fairly troublesome. As a consequence, the most cancers may be fairly superior by the point a prognosis is made. (Lymphoma is just not the one the illness that creates swollen lymph nodes; this symptom doesn’t assure your dog has lymphoma.)
Because multicentric lymphoma accounts for almost all of circumstances, an aspirate of an enlarged peripheral lymph node is often ample to succeed in a presumptive prognosis of the most typical forms of lymphomas.
Although prognosis from cytology is pretty simply obtained, it doesn’t differentiate the immunophenotype (B versus T lymphocyte). Histopathologic tissue analysis (biopsy) is required with the intention to establish the sort with the method of immunophenotyping.
Immunophenotyping is a molecular take a look at often carried out by stream cytometry (a complicated laser expertise that measures the quantity of DNA in most cancers cells) that classifies lymphomas by figuring out if the malignancy originates from B lymphocytes or T lymphocytes. Determining whether or not a lymphoma is B-cell or T-cell is invaluable because it supplies the very best predictive worth; the adage “B is better, T is terrible” displays this in its easiest type.
Diffuse massive B-cell lymphoma (DLBCL) is the most typical histologic subtype of lymphoma occurring in dogs. Most intermediate to excessive grade lymphomas are B-cell lymphomas – they have a tendency to reply higher and longer to chemotherapy than T-cell lymphomas; nonetheless, dogs with T-cell lymphoma have been recognized to enter remission for a number of months.
Another phenotyping take a look at, the PCR antigen receptor rearrangement (PARR), can decide whether or not the cells are indicative of most cancers or extra per a reactive course of. For instance, as a result of the lymph nodes within the space of the jaw are reactive, the PARR take a look at might help decide if most cancers is current or if the dog simply badly wants his tooth cleaned. The PARR take a look at will also be used to detect minimal residual illness. Research is constant to find out if this will probably be a helpful medical marker of early recurrence.
To verify the affected person’s total well being, an entire bodily examination will probably be carried out; extra diagnostics typically embrace a blood chemistry panel, urinalysis, x-rays, ultrasounds, and different types of diagnostic imaging (these exams are additionally used for staging the illness).
In explicit, it is very important display screen for hypercalcemia. Hypercalcemia is a situation through which the hormone PTHrP (parathyroid hormone-related peptide) creates harmful elevations within the blood calcium stage. This well-documented syndrome is related to lymphoma in dogs and is most frequently seen in T-cell lymphomas.
About 15% of dogs with lymphoma total may have elevated blood calcium ranges at prognosis; this will increase to 40% in dogs who’ve T-cell lymphoma. The situation causes extra medical indicators together with elevated thirst and urination, and, if left untreated, may cause severe harm to the kidneys and different organs and be life-threatening.
Unfortunately, because of the quickly progressive nature of lymphoma, selections relating to remedy must be made as quickly as attainable after prognosis. Unlike most different types of most cancers, lymphoma requires pressing care; with out remedy, the median survival time is one month after prognosis. Therefore, homeowners must be ready to begin remedy on the day of prognosis, or inside a day or two at most.
Once a prognosis of lymphoma has been made, the stage (extent) of the lymphoid malignancy must be decided, and to evaluate this, a number of exams are beneficial: lymph node aspirate, full blood depend, chemistry panel, urinalysis, phenotype, thoracic and chest radiographs, belly ultrasound, and a bone marrow aspirate.
Staging is prognostically vital; basically, the extra in depth the unfold, the upper the stage, the poorer the prognosis. However, even dogs with superior illness may be efficiently handled and expertise remission. These exams additionally present details about different circumstances which will have an effect on remedy or prognosis. The World Health Organization (WHO) five-tier staging system is the usual used to stage lymphoma in dogs:
Stage I: Single lymph node is concerned.
Stage II: Multiple lymph nodes inside in the identical area are affected.
Stage III: Multiple lymph nodes in a number of areas concerned.
Stage IV: Involvement of liver and/or spleen (usually lymph nodes are affected however it’s attainable that no lymph nodes are concerned).
Stage V: Bone marrow or blood involvement, no matter different areas affected and/or different organs aside from liver, spleen and lymph nodes affected.
In addition, there are two classes of medical substages. Dogs are categorized with substage A if medical indicators associated to the illness are absent, and categorized as substage B if medical indicators associated to the illness are current (systemic indicators of sickness).
Although canine lymphoma is a fancy and difficult most cancers, it is likely one of the most extremely treatable cancers and most dogs reply to remedy. In reality, many dogs with lymphoma outlive animals with different ailments similar to kidney, coronary heart, and liver illness. While lymphoma is just not curable, the purpose with remedy is to shortly obtain remission for the longest interval attainable thus giving dogs and their homeowners extra high quality time collectively. It is crucial that the kind of lymphoma is recognized as the sort impacts remedy and prognosis. And as a result of lymphoma is a really aggressive most cancers, it is very important start remedy as quickly as attainable.
Since lymphoma is a systemic illness that impacts the entire physique, the best remedy can also be systemic within the type of chemotherapy, which supplies many dogs with extended survival occasions and glorious high quality of life, with little or no unintended effects.
The particular sort of chemotherapy remedy used will fluctuate primarily based on the kind of lymphoma. Other elements to think about when selecting a protocol are the disease-free interval, survival time, typical period of remission, scheduling, and expense. Again, dogs with B-cell lymphoma have a tendency to reply way more favorably to remedy than these with T-cell.
Because lymphoma is so frequent in dogs, there was a considerable quantity of analysis and testing of many various mixtures of chemotherapy therapies. Multiagent chemotherapy protocols are thought-about the gold normal of remedy and have proven to offer the very best response by way of size of illness management and survival charges, as in comparison with single agent protocols.
The Madison Wisconsin Protocol, often known as UW-25 or CHOP, is a cocktail of medicine modeled after human lymphoma therapies and is broadly thought-about to be the best remedy for intermediate- to high-grade canine lymphomas. This protocol makes use of three cytotoxic chemotherapy medication – cyclophosphamide, doxorubicin (hydroxydaunrubicin), and vincristine (model identify Oncovin) – together with prednisone (CHOP). The prednisone is often given every day at dwelling as a pill with the rest of the protocol brokers administered by an oncology specialist.
On common, 70 to 90% of dogs handled with CHOP expertise partial or full remission. For dogs with B-cell lymphomas, 80 to 90% may be anticipated to realize remission throughout the first month. The median survival time is 12 months with 25% of sufferers nonetheless alive at two years. For T-cell lymphoma, about 70% will obtain remission with a median of six to eight months survival.
Other remedy choices embrace the COP chemotherapy protocol (cyclophosphamide, Oncovin [vincristine], and prednisone), vincristine and Cytoxan; single-agent doxorubicin; and and lomustine/CCNU. As a main remedy, single-agent doxorubicin may end up in an entire remission in as much as 75% of sufferers with median survival time of as much as eight months, although cumulative remedy with doxorubicin could end in cardiotoxicity, so the protocol could also be contraindicated in any dog with proof of or a historical past of pre-existing coronary heart illness. Lomustine/CCNU is reported to be the best remedy for cutaneous lymphoma.
Remission is the situation through which the most cancers has regressed. Partial remission implies that the general proof of most cancers has been lowered by at the least 50%; full remission signifies that the most cancers has change into undetectable to any available diagnostic screening (but it surely doesn’t imply that the lymphoma has left the dog’s physique, solely that it has been handled into dormancy).
A dog in remission is basically indistinguishable from a cancer-free dog. The lymph nodes will return to regular dimension and any sickness associated to the most cancers often resolves. Overall, there may be roughly a 60 to 75% likelihood of attaining remission whatever the protocol chosen.
Studies present that the common time for a dog to be in remission the primary time is eight to 10 months, together with the interval of chemotherapy administration. Remission standing is frequently monitored; for dogs with enlarged lymph nodes it sometimes entails checking the scale of the lymph nodes. For dogs with different forms of lymphoma, periodic imaging could also be beneficial. The Lymphoma Blood Test (LBT) from Avacta Animal Health will also be used monitor standing since LBT ranges can improve lower than eight weeks earlier than relapse.
Unfortunately, remission ultimately relapses usually, however many dogs can restart chemotherapy with the hope of regaining remission standing. At occasions, the identical chemotherapy protocol could also be used. For dogs efficiently handled initially with the CHOP protocol, restarting CHOP on the time of the primary relapse is often beneficial. About 90% of these handled with a second CHOP protocol will obtain one other full remission, nonetheless, the period is often shorter than the primary time.
If a affected person doesn’t reply to the primary CHOP protocol earlier than completion or the remedy fails through the second protocol, the usage of rescue protocols may be tried; these consist of medicine that aren’t present in the usual chemotherapy protocols and stored in reserve for later use.
Commonly used rescue protocols embrace LAP (L-asparaginase, lomustine/CCNU, and prednisone) and MOPP (mechlorethamine, vincristine, procarbazine and prednisone). These are much less more likely to end in full remission and some dogs will solely obtain a partial remission, with an total response charge of about 40 to 50%, and a median survival charge of 1.5 to 2.5 months.
Because most cancers cells evolve over time, the illness can change into proof against sure medication. Further therapies may be given, however it could actually change into harder to realize remission a second or third time and there doesn’t look like any substantial impact on survival occasions.
OTHER TREATMENT OPTIONS
Here are some compelling alternate options to think about along with the usual protocols described above:
Prednisone. This is often a element of most lymphoma remedy protocols as a result of it truly destroys lymphoma cells. It may even be administered as a standalone remedy. The common survival time with out chemotherapy is about one month however treating with prednisone alone can improve this to about two to 3 months, with a median of 50% responding.
Tanovea-CA1 (rabacfosadine). This is a promising new development in treating canine lymphoma. This drug has been conditionally authorized to be used by the U.S. Food and Drug Administration (FDA), pending a full demonstration of its effectiveness (extra discipline research are presently going down to acquire full approval).
Tanovea-CA1 is designed to focus on and destroy malignant lymphocytes and can be utilized not solely to deal with dogs which have by no means obtained any remedy but in addition these not responding to chemotherapy. It has demonstrated a 77% total response and a 45% full response charge. It is run by veterinarians in 5 therapies each three weeks through intravenous infusion and is proven it to be usually well-tolerated.
Bone Marrow Transplant. One of the most recent approaches to treating canine lymphoma is the bone marrow transplant – a type of stem cell remedy – modeled after a way utilized in human medication. The course of entails the dog receiving and finishing CHOP remedy (which places the most cancers in remission); the harvesting and preservation of wholesome stem cells from the affected person; the administration of radiation to destroy any remaining most cancers cells; and the returning of wholesome cells to repopulate and restore blood cells.
In people, the treatment charge is about 40 to 60%; the process has been decided to be protected to be used in dogs with treatment charges of 33% for B-cell lymphomas and 15% for T-cell lymphomas. The course of is dear ($19,000 to $25,000) and requires about two weeks of hospitalization. Currently there are solely two places within the U.S. providing the process: the North Carolina State College of Veterinary Medicine (in Raleigh) and Bellingham (Washington) Veterinary Critical Care.
At some level lymphomas change into proof against remedy and no additional remissions may be obtained. Eventually the uncontrolled most cancers will infiltrate an organ (typically the bone marrow or the liver) to such an extent that the organ fails. Under these circumstances, it’s best to give attention to prime quality of life for the longest attainable survival time.
Like most cancers, the eventual prognosis for dogs with lymphoma isn’t very uplifting. But it’s a very treatable most cancers, and dogs dwell nicely and longer with remedy. Several prognostic elements have been recognized for estimating a dog’s response to remedy and survival time:
Dogs with indicators of systemic sickness (substage B) are likely to have a worse prognosis than dogs with substage A.
Dogs with lymphoma histologically categorised as being both intermediate- or high-grade are typically extremely attentive to chemotherapy, however early relapse is frequent with shorter survival occasions.
Dogs with lymphoma histologically categorised as being low-grade have a decrease response charge to systemic chemotherapy but expertise a constructive survival size benefit when in comparison with intermediate- or high-grade tumors.
Dogs with T-cell lymphomas have a shorter survival time in comparison with dogs with B-cell primarily based malignancies.
Dogs with diffuse alimentary, central nervous system, or cutaneous lymphoma are likely to have shorter survival occasions when in comparison with dogs with different anatomic types of lymphoma.
Presence of hypercalcemia or anemia or a mediastinal mass are all related to a poorer prognosis.
Intestinal lymphoma has a really poor prognosis.
Expectations for circumstances with Stage V lymphoma are a lot decrease than these assigned to Stages I to IV.
Prolonged pre-treatment with corticosteroids is commonly a detrimental prognostic issue.
Ultimately, the estimates for survival occasions rely on the kind of lymphoma mixed with the stage and the remedy choice chosen (if any).
In the absence of remedy, many of the dogs recognized with lymphoma succumb to the illness in 4 to 6 weeks.
The median survival time with a multi-agent chemotherapy protocol is 13 to 14 months.
Traditional chemotherapy leads to complete remission in roughly 60 to 90% of circumstances with a median survival time of six to 12 months.
In about 20 to 25% circumstances, dogs dwell two years or longer after initiation of ordinary chemotherapy remedy.
Dogs handled with rescue protocols have a survival charge of 1.5 to 2.5 months.
Studies point out that dogs who underwent splenectomy present a median survival charge of 14 months.
Complete treatment is uncommon, however not unprecedented. Bone marrow transplants present promise and potential for elevated treatment charges.
Above all, do not forget that prognoses are solely tips primarily based on common accumulative experiences. They are numbers, and as an expensive pal and veterinary oncologist has mentioned to me many occasions, “Treat the dog, not the numbers.”