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Rennie's Page

Transitional Cell Carcinoma Resources

This page was created in memory of Nuvak's Serendipity (known as Rennie). Rennie was a wonderful, outgoing, and loving Samoyed-a friend to everyone she met. She was athletic, agile, and totally fearless. She died at age 10 after a year-long fight with transitional cell carcinoma (Bladder Cancer or TCC). We miss her still.

Rennie's Page is intended to be the resource I wish my veterinarian and I had when Rennie was diagnosed. This page is not intended to substitute for consultation with a veterinarian! Please discuss this information with your own vet, and verify its accuracy for yourself.

Contents: What is a Samoyed? What is Transitional Cell Carcinoma? (TCC) How is Transitional Cell Carcinoma diagnosed? How is TCC treated in Dogs? Supportive Treatment Treating the Terminally Ill Pet Living with an Incontinent Housepet Rennie's Death Contact me

What is a Samoyed?
A Samoyed is one of three Arctic breeds of dog recognized by the American Kennel Club. They were developed to serve as guard dogs, reindeer herders, and sled dogs by the Samoyede people of Siberia. They are medium-size white dogs with black noses, dark eyes, and a double coat.

Samoyed puppies are irresistably cute. Pet store owners know this. Many people purchase a sweet, fluffy puppy with little information about how to properly train it to become a well-mannered adult. Samoyeds are loving, but independent and stubborn by temperment. A well-trained Samoyed is an excellent pet: affectionate, watchful without being aggressive, good with children. An untrained Samoyed will attempt to dominate the household and will destroy shoes, toys, furniture, wallboard, carpet, will turn the yard into moonscape of craters, bark the neighbors' nerves to a frazzle, eat the siding off the house, and become an escape artist.

Untrained Samoyeds are frequently given up to humane societies and rescue organizations by their frustrated owners. Such dogs often make excellent pets in the hands of a person willing to provide consistent discipline and TRAINING.

Please do not buy an adorable Samoyed puppy unless you first educate yourself about the breed, and are willing/able to provide training.

What is Transitional Cell Carcinoma (TCC)?
Transitional Cell Carcinoma (TCC) is a cancer of skin cells, often the skin cells lining the bladder. It is classified as Stage 0 to Stage 4 depending upon how localized the tumor is: whether it is confined to the skin layer or penetrates surrounding muscle and/or tissue or whether it is metastatic (has formed new tumors in distant sites). In humans, shallow, localized tumors may receive treatment designed to specifically target the lining of the bladder. Localized bladder tumors are successfully treated by surgical removal of part or all of the bladder. If all the bladder is removed, urine is collected in an external pouch. Sometimes surgery is combined with drug treatment (chemotherapy) or radiation therapy. When the disease is caught early, these treatments can be quite effective.

Advanced, metastatic bladder cancer is a serious disease, currently incurable for more than 80% of patients. It is usually treated with multiple-drug chemotherapy. This sort of intensive chemotherapy has severe side effects but 1 in 7 patients may achieve a remission. Single-agent chemotherapy has a remission rate of less than 1 in 20. Hopefully, research will continue to improve cancer treatments.

How is transitional cell carcinoma diagnosed?
Traditionally, transitional cell carcinoma was diagnosed by performing surgery, removing a tissue sample, and sending the tissue sample to a histology lab for analysis. New: Abbott Labs has developed a kit for diagnosis of transitional cell carcinoma from a urine sample. The kit detects a bladder tumor glycoprotein complex specific to transitional cell carcinoma. If you suspect transitional cell carcinoma, ask your veterinarian about this test.

How is transitional cell carcinoma (TCC) treated in dogs?
Several veterinary studies about different methods of treating pet dogs with TCC have been done studying a number of potential treatments:

1. 
   
drug therapy with piroxicam
2. chemotherapy with cisplatin
3. laser phototherapy ("photodynamic therapy")
4. radiation therapy
5. surgical removal of the bladder
6. other therapies

A note about terminology. In these studies, complete remission is defined as disappearance of measurable tumor (there may still be cancer cells present). Partial remission is defined as 50% or more reduction in tumor volume without development of new tumors. Stable disease is defined as less than 50% change (increase or decrease) in tumor volume without development of new tumors. Progressive disease (PD) was defined as 50% or more increase in tumor volume or development of new tumors at any time. So "Stable Disease" does not mean that the tumor is not growing; it means the tumor hasn't increased by more than 50% in size over the time studied.

Piroxicam Therapy Piroxicam is a non-steroidal antiinflammatory drug (NSAID), primarily used to treat human arthritis under the trade name Feldene (Pfizer). It has been studied in several species as a chemopreventive or tumor suppressant drug. Dr. Deborah Knapp of Purdue University School of Veterinary Medicine studied the antitumor effects of piroxicam in 34 dogs with TCC. 2 dogs achieved remission and 22 dogs partial remission or stable disease by the definition of the study. 7 of the 34 dogs lived for more than a year. These are the best results of any therapy for TCC to date. Anecdotally, others have not had this degree of success. Piroxicam appears to have no direct antitumor activity. Rather it appears to act indirectly, possibly by preventing PGE2-mediated immune suppression.
Advantages Like all NSAIDs, piroxicam is a strong analgesic. So if it does nothing else, it will relieve the dog's pain. It is a relatively inexpensive drug. The therapy is totally non-invaisive.
Disadvantages Like most NSAIDS, piroxicam irritates the gastrointestinal tract and may cause GI bleeding. Some dogs may not be able to tolerate piroxicam. This effect may be reduced by administering acid-blocking drugs such as misoprostol (Cytotec).
Complications Exact dosage is important, both for therapeutic effect and to avoid GI irritation. The correct dose is 0.3 mg piroxicam per kg of dog per day. Once a day is adequate dosing to maintain a relatively constant level of drug; more drug will not work better and will have a higher risk of GI complications. The correct dose for your dog may require reweighing of commercially available capsules. I did this myself, but most people should be able to find a friendly dog-loving pharmacist who will do this for a small fee. A small neighborhood pharmacy might be your best choice for this.

Chemotherapy with Cisplatin Cisplatin chemotherapy of dogs with TCC has been studied by Dr. Wayne Shapiro of UC Davis School of Veterinary Medicine and by Dr. Deborah Knapp of Purdue. There have been no complete remissions of TCC documented in dogs treated with Cisplatin chemotherapy, even at levels where considerable side-effects were observed. Partial remissions have occurred (1 in 6 at best) and stable disease has been observed for as few as 1 in 4 or as many as half of the dogs treated, with a mean survival time (180 days) comparable to the piroxicam study.
Advantages It may prolong the dog's life and possibly improve it (reduce the tumor). Cisplatin has a direct antitumor effect.
Disadvantages Cisplatin is a seriously toxic drug. It is believed to work by cross-linking DNA. This has a stronger effect on cells which are growing faster (such as tumor cells) but can potentially affect most cells in the body. Cisplatin may cause short-term effects such as nausea and vomiting, and long-term effects such as renal toxicity.
Complications Cisplatin must be administered intravenously. The dog must stay (at least) all day in the veterinary hospital. Treatment by a vet familiar with how to minimize or control side effects and what to monitor is essential. Treatment is expensive (several hundred dollars for the drug alone in a medium-size dog) and must be repeated every 21 days.

Photodynamic Therapy is a relatively new form of cancer treatment. The idea is to administer a nontoxic dye which will make all cells sensitive to light, then target a laser specifically at the tumor. The good news is that this therapy is available to pet owners through Dr. Elsa Beck in Detroit, MI. The bad news is that no controlled studies have been done, so it is very difficult to evaluate the effectiveness. When I spoke to Dr. Beck's associate Dr. Cyman, 15 dogs with TCC had been treated. Several improved, and lived for a year or more. Several were also receiving chemotherapy. Several metastesized. This is not a technique which has produced complete remission.
Advantages Specific targeting to tumor cells. Can combine with other therapies. Reported improvement in symptoms in all dogs treated.
Disadvantages The whole dog will be photosensitive and must be kept out of the sun for 4 to 6 weeks. This might not be a big deal for a toy poodle but it's a major quality of life issue to an enthusiastic athletic dog. The dog's clinical symptoms are worse for about a week, then improve. There is potential for scarring after repeated treatments.

Radiation Therapy There have been no reported remissions from radiation therapy. One study of radiation therapy done during surgery reported that the urinary bladder or ureter scarred and stiffened when irradiated, and that tumor control was poor. One owner told me that radiation therapy definately helped her TCC-afflicted pet's symptoms, but radiation therapy also made her pet ill.
Advantages Temporary alleviation of symptoms.
DisadvantagesSee Above. Not an option we considered.

Surgical removal of the bladder There have been several studies in which dogs had their bladders surgically removed. Since it is impossible to explain to a normal, active dog that the little bag they are wearing must be kept clean and left alone, dogs whose bladders were completely removed had the ureters surgically attached to the large intestine so that urine flowed into the bowel (ureterocolonic anastomosis). All of the dogs so treated developed high levels of nitrogen in the blood (azotemia). This causes nausea/vomiting and neurologic problems. The dogs lived one to five months. Dogs whose bladders were only partially removed did better; six of 11 dogs lived more than a year. The tumor was not completely removed, and after a time appeared to recur in most cases.
Advantages If the tumor can be removed without disturbing the ureters and urethra, surgery could be a useful option and could make drug therapy with piroxicam or cisplatin more effective.
Disadvantages If the ureters and urethra must be disturbed, surgery will cause serious health problems. Rennie's tumor was located in the trigonal region of the bladder (where the ureters enter from the kidneys, and the urethra exits) so surgical removal wasn't an option.
Complications Transitional cell carcinomas are extremely invasive tumors which spread rapidly, and which can even be seeded (form new tumors) by surgery unless exquisite care is taken. If you choose surgery, find a really good surgical vet. Oh, yes, surgery is expensive.

Other Treatments There are a variety of natural treatments available to "cure" cancer. Unfortunately none of their effectiveness has been evaluated in carefully controlled studies so it is difficult to evaluate whether and how effective these treatments might be. Commonly suggested treatments include Essiac and Shark Cartiledge. The effectiveness of natural treatments is a highly emotional issue for some people who believe that there is a conspiracy between government and pharmaceutical companies to stifle recognition of inexpensive herbal treatments. I don't believe in such conspiracies. My personal attitude towards herbal remedies is "if it does no harm, is not invasive, and doesn't prevent other treatments why not try?" The "does no harm" can be difficult to evaluate. More may not be better with immune stimulant therapy. Also "natural" does not necessarily mean "non-toxic". Herbal preparations can be toxic or cause side effects, just like chemically synthesized drugs.
Essiac is available from Shawnee Moon Herbiceuticals, among other places. Shark Cartiledge is available mail-order from Puritan Vitamins, among other places. They certainly didn't cure Rennie, but they didn't hurt and they may have helped.

Bladder Infections
Because TCC will damage the epithelial (skin) cells lining the bladder, TCC makes the dog particularly susceptible to frequent bladder infections. Bladder infections are very painful (for dogs and for people). Treatment with the appropriate antibiotic is essential. If the infection is not treated with an effective antibiotic, the dog may become listless, uninteresed in playing, inappetant, and even exhibit signs of pain such as emitting a sharp whimper when trying to move. It is difficult to separate these symptoms from symptoms caused by the cancer except by treating the infection with the appropriate antibiotic and seeing if the dog improves. For Rennie, improvement was dramatic up to the last month of her life. In my experience, aggressive treatment with the correct antibiotic was essential to maintaining Rennie's comfort and quality of life.

However, continuous antibiotic treatment should be avoided in order to minimize selecting for antibiotic-resistant bacteria. Urine cultures and antibiotic sensitivity testing must be done. Dr. Deborah Knapp suggested urine cultures at 3 week intervals. I found it helpful to do cultures and limited sensitivity testing every week. I could tell by Rennie's behavior when the antibiotic had stopped working, but her behavior couldn't inform us about the correct antibiotic. It may be necessary to call around and negotiate to find a local lab which can produce results on a reasonable time scale. My vet shipped samples to an out-of-town lab, and it just didn't cut it for turnaround time.

Useful drugs include: Amoxicillin, Primor (sulfa/amethopterin), Clavamox (veterinary Augmentin), Baytril, Naxcel, and Amikacin. Do not simply rely upon alternating drugs. Rennie developed drug resistant bacteria, and a normal two week course of antibiotic therapy was not sufficient to allow resistant bacteria to die out. It took about three weeks from stopping a drug for bacterial resistance to that drug to disappear.

Personal observation: even though we were careful to follow a full course of treatment with each antibiotic and not to treat with multiple antibiotics at the same time, Rennie was living proof that natural selection in a single patient over several months outside a hospital setting is sufficient to eventually produce multiply resistant bacteria. This is very scary stuff. Eventually, the only antibiotics which will work are those administered by injection (Naxcel, Amikacin). Giving subcutaneous injections is not difficult; your vet can teach you. You may need a prescription for syringes in your state. Proper disinfection to kill off any stray bacteria requires care and thought.

Warning Most of the bacteria which cause bladder infections in a dog with bladder cancer are bacteria normally found in the environment and are not dangerous to healthy adults. Still, care should be taken. Wash the dog's bedding and clean-up rags with bleach, wash floors and clean urine spots with disinfectant using a mop head you can launder with bleach. Wear disposable gloves while cleaning up or cleansing the dog and wash hands thoroughly with disinfectant soap afterwards. Do not wash hands or place cleaning supplies or dog supplies in human food preparation areas. The drugs used to treat dogs and those used to treat people are essentially the same. If there is an infant or an immune-compromised person in your household, drug-resistant bacteria could be EXTREMELY dangerous to them. You may have to make a difficult decision. Discuss the issue of antibiotic therapy, disinfection, and drug resistance carefully with your vet and do not let your concerns be dismissed lightly. Your vet may not be sufficiently familiar with the kinds of bacterial resistance which can emerge over six to nine months of antibiotic therapy and may need to consult with an expert at a veterinary teaching hospital. Get good instructions about how to disinfect effectively. A nurse who does ICU work is a good source. Get someone to watch you and point out potential routes of contamination. Do this early, so you have good habits built up before there's a potential problem. I don't mean to be alarmist, or anything. None of the people who cared for Rennie had a bit of a problem. But better safe than sorry.

Pyrimidine, no
People with urinary tract infections are given the drug pyridimine along with antibiotics. Pyridimine is a dye which serves as a urinary tract anesthetic (I have no idea how someone figured that out) while turning the urine a bright orange which stains permanently. If you can contemplate the concept of having bright-orange dots all over your domicile, you might ask "why not give pyrimidine to my dog?" At least, I asked. It turns out there is a study of pyrimidine effects on dogs, and it's not good; it damages their tear ducts causing irritated, dry eyes (keraconjunctivis sicca).

Urinary Acidifiers
The number of infections can be reduced by keeping the urine slightly acid. This discourages bacterial growth. We gave Rennie Vitamin C to acidify her urine (500 mg twice a day). One pet owner gave her pet cranberry juice jello, made by combining 1 packet of unflavored gelatine with 1/4 c cold cranberry juice and adding 3/4 c boiling juice then chilling. I thought this tasted great, but Rennie didn't like it. Don't give orange juice, the citric acid will have the opposite effect. You can check the acidity of your dog's urine with "pH paper" from a pharmacy or laboratory supply house. Discuss how to use this and the desired acidity with your vet.

Inappetance
is a common problem in cancer patients. Evidently the tumor secretes factors which (among other things) suppress appetite. Pain or discomfort also remove the desire to eat. Rennie had never been a picky eater (dry kibble twice a day) but as her illness progressed, she became less and less interested in eating. Chicken broth on high quality kibble helped for a long time. Try different brands to see if one is more appealing than another. Near the end, she would often act as though she wanted to eat, and even take a mouthful of food, but then let it drop from her mouth as though it just didn't taste good.

A dog with a failing appetite can usually be tempted by canned food or by liver and garlic and other aromatic goodies. Paradoxically, it seemed easier to coax Rennie with bland food such as cream cheese or scrambled egg. A friend who nurses cancer patients told me it is not uncommon for cancer patients to find that a favorite food with strong smells or flavors is now "too much". We gave Rennie vitamins and got calories in her any way we could. Frozen yogurt and cream cheese pack lots of calories into a little volume. Cream cheese is also a good way to administer pills. As long as she would eat it, we gave Rennie plain unflavored yogurt three times a day. I feel it helped soothe her stomach and avoid digestive upsets. Dogs who can't tolerate dairy products can sometimes tolerate yogurt (frozen or fresh) and cream cheese. Cooked lamb mixed with rice was the food she would eat at the end.

Treating the Terminally Ill Pet

The decision about how to treat a terminally ill pet who is a beloved member of the family is highly emotional and personal. It is my purpose to provide information about available treatments for this invasive form of cancer and to describe the techniques we evolved for keeping our girl as comfortable as possible and for living with an increasingly incontinent housepet. Caring for such a pet requires a large investment of time, effort, money, and emotional energy. We were very fortunate to be in a position to give Rennie these things without seriously shortchanging our families or ourselves. Even so, it was difficult.

When treating a terminally ill pet, one must always consider the pet's comfort and quality of life. A person can consider the risks, and side effects of a course of treatment, weigh these against the potential benefits, and make an informed choice. We have to make these choices for our pets, always keeping in mind that a pet cannot look to the future in the same manner as a person.

Our choice was to treat Rennie only in ways which were relatively uninvasive and which little impact on her quality of life, only for so long as she seemed able to enjoy life. If our situation had been different, I feel that humane euthanasia would have been preferable to exiling her from the family she'd always known or allowing her to live with the pain of improperly treated bladder infections.

Whatever your choice is, do not let anyone make you feel guilty for doing too little or for doing too much. Follow your heart.

Living With An Incontinent Housepet
There are essentially two issues:

1. Maintaining the health of the pet's skin
2. Maintaining the house in an acceptable state

People differ widely in their definition of 'acceptable' house, so I'm going to focus on what we did to maintain the health of Rennie's skin. This also maintained our house in a state we could manage to live with. A dog cannot be permitted to lie in urine or have continual contact between urine and skin. In addition to problems with odor, the skin will become irritated, raw, and subject to infection. Please read the section on disinfection under

Rennie had been accustomed to crates and wire "exercise pens" since puppyhood. For a dog who is accustomed, these are not incarceration but a comfortable, secure "den". To keep her from lying in urine at night and while we were at work, I designed and sewed special "xpen rugs". These consisted of a double layer of polyester pile fabric, sized to cover the entire exercise pen. I was able to buy inexpensive remnants at a local fabric warehouse. I sewed them together with a layer of dacron quilt batting in the center, then machine quilted them and sewed shoelaces to the corners and the center of each side. Rennie's xpen was then set up as follows (from the floor up):

1. Cardboard
2. Plastic
3. A thick layer of newspaper to absorb liquid
4. The xpen rug, which did not absorb liquid
5. Sometimes extra pile rugs for Rennie to arrange

When we were home, we used adult diapers so that Rennie could walk around the house freely. We cut a hole for her tail, shortened the straps, and crossed them over her back. Other people suggested placing a tarp with several absorbant pads for the dog to lie upon, but Rennie was a little too mobile for that suggestion to work well for us. The rare urine spot was sprayed with disinfectant, then sponged with a mixture of 1 teaspoon white vinegar per quart of warm water or 1 teaspoon liquid fabric softener per cup of warm water to remove scent. I like Simple Green cleaner for tile or linoleum and the least expensive commercial foam spot remover to remove spots from carpets, but several people swear by Orange Glo Cleaner [available from Orange Glo Northwest (800)672-6456]. I had some orange-based Flea Dip which was totally useless for killing fleas (I sprayed some on 4 live fleas in a jar and 4 out of 4 were still alive a week later), but it made a great air freshener when diluted according to package directions.

Rennie's Death
More details about Rennie and the story of Rennie's last day. Contains a number of pictures.

If you have comments or suggestions about this page, or links which you feel should be included, please email me: sydney at hoecad dot com

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since August 26, 1997