Lymphoma/IBD: Surgical Biopsy Thoughts

ErinEC

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Hello, I will spare the last 5 weeks of what my little Gob (pronounced Jobe, like the arrested development character) has been going through and say that we got an ultrasound yesterday showing an enlarged lymph node near his kidney and inflammation in the pancreas. The vet is assuming it is lymphoma or IBD, and we will be doing a small needle aspiration in 2 days to try and diagnose.

The vet warned me that the results are often inconclusive and a surgical biopsy would need to be done to determine which it is, so we can either start chemo or just stick with treating the inflammation.

A different vet (the local emergency vet) said she wouldn't put her sick cat through the surgical biopsy. But of course I'm reading and seeing that chemo can add a good amount of time and quality of life, rather than just treating with steroids and giving them a month or two until the cancer takes over. But of course they will not administer chemo without proof that it is definitely lymphoma.

Has anyone had to make this decision?

(FYI, we will be starting steroids the second we get the small needle biopsy over with in 2 days, since he's just so sick.)
 

Kieka

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I'd wait to see what the initial biopsy says and see how he handles the medications from that. If he handles the medications decently and further biopsy is needed, then I would go for it. For me in situations like this it comes down to what can I live with. Can I live with skipping a biopsy and potentially missing something that could have made a difference? No.

That said, I did have a cat with cancer where we did everything we could. Including imagining scans and chemo through IV. And yes, he handled it fairly well but you could tell by the end he was tired. In the end, it didn't make a difference for him and we only bought him 6 months. I wouldnt trade those 6 months for anything but I do have moments of doubting if it was worth it to him. He did get the last month vet visit free and our vet came to the house when it was his time.
 

fionasmom

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Chelsea has intestinal lymphoma, dxed through symptoms alone by my vet. The usual steps are needle aspiration, sometimes ultrasound, both of which can be inconclusive, leading to the invasive biopsy. You have already found this out. Chelsea is 10 1/2 and for about 8 1/2 years was almost dangerously difficult to handle, at which point she moved to just very hard to manage. So when the question of lymphoma came up, I declined all tests and we started her on pred. I could just picture bringing her home from an invasive procedure and being entirely unable to handle her if she needed extra care. On the advice of daftcat75 daftcat75 I asked the vet if we could begin to use leukeran without the testing. She agreed and we proceeded to that protocol. This particular vet will not operate on older and debilitated cats as a policy as she says that it never works out....unfortunately, my experience with 11th hour surgery with both dogs and cats has borne this out. Her own cat had a surgical biopsy for intestinal lymphoma and she said that she was sorry that she put him through that.

Unless I am misreading your post, you have been offered that option as well. If little Gob is a good patient, I would not decline the needle biopsy....I assume that he is up to having it safely....and you have it scheduled for a couple days from now. Evaluate those results and then move on from there.

One vet is saying that doing leukeran/chlorambucil without the surgical biopsy is okay and one is not? Just making sure.

Chelsea has been on the meds since about June; her treatment started late in the game I am sure, but she is still here and just went in the other day for bloodwork.
 

daftcat75

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A few thoughts:

1. You'll be better served by an internal medicine specialist if you can find one. This is their expertise. It's my belief that my vets were over their head with Krista's case. At some point, they were just "pred and pray." 🤦‍♂️

2. Don't consent to endless pred without a game plan to monitor for long-term effects. Ideally, there should be an initial period where you get things under control. Then you should be seeking to taper to the minimum effective dose. Preferably that's not a daily dose. It is also my belief that Krista never recovered even after remission because daily pred at too high a dose weakened her too much.

3. Medicine alone, whether pred or pred plus chemo, may not be enough. I wish we learned this lesson sooner. The fish flakes that I was using to wrap her pred halves--because she was impossible to pill and all the pill dough/pill pockets had trigger ingredients--those flakes were a trigger food. She never fully achieved remission until we removed all the triggers. Interestingly, one of her compounded medicines turned out to be a trigger too. We never did figure out if it was the flavoring or some ingredient in the compounding. We had months and months of poop nonsense (it presented like both constipation and diarrhea) and post-poop barfing. Once the trigger ingredients were removed--all of them--she finally achieved remission. Perfect poops. No post-poop barfing. It's bittersweet that it took so long. But I'm grateful that she did have a month or two of remission before she passed.

4. Compounding. Between pred and chemo, you will be giving daily or nearly daily medicine. Compliance is very important! If you don't think you'll be able to pill him that often, look into having the medicines compounded. I wish I had Krista's pred compounded sooner. We would have no doubt reached remission sooner. That last month or two, she took pred as a transdermal cream and her chemo as an ultra-concentrated (the highest concentration so I could give the smallest amount) anchovy flavored liquid. Sometimes I had to mix that with salmon oil to get her to finish it. If you're in the US, I found Wedgewood to be very helpful and knowledgeable. When I discovered that Krista was having a reaction, possibly to a flavoring, they rushed out the medicine in a different flavor for me to try. By that point, I had already worked out how to get Krista to eat the crumb of a pill (1/4 of a pill) so we didn't have to rely on the compounded form. But I still greatly appreciated the gesture and the effort.
Veterinary Pharmacy
 

daftcat75

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In the case where they clearly note on the ultrasound that it is suspected "small cell lymphoma or IBD", then yes, you can ask your vet to try the leukeran (chlorambucil) without the surgical biopsy. In this case, the surgical biopsy is only confirming what they already suspect. Given your cat's age and health, the diagnosis is riskier than the drug.

However...

If they are uncertain what kind of lymphoma it might be, then asking your vet for chlorambucil when another drug might be more appropriate is shooting in the dark. In this case, I would ask your vet to speculate which it might be and what drug would be used. Then ask him if using the drug without confirmation poses more or less harm than a surgical biopsy in an older, weakened cat. This is where a specialist would be most useful. She could put a few alternatives on a page and tell you the risks of each to help you decide whether to do the surgical biopsy, or give "informed consent" that you're going to try something else without the confirmation diagnosis.
 
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ErinEC

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I wanted to respond since you've all been very kind in the help you've given. The vet was sure we were dealing with lymphoma, but the fine needle aspirate showed a bunch of infection and no cancer. They did wonder if there was still cancer below it, so that diagnosis was not ruled out. We immediately put him on 2 antibiotics and he stayed in the hospital 4 nights. His fever came down right away, so we were hoping things were looking up. Long story short, that was a false sense of security. A week of treatment later it turns out he actually has FIP. No one suspected it since he's only 10. I brought him to the emergency vet for heavy breathing today and they found fluid everywhere inside him and were able to make the diagnosis. When you start piecing everything together, all the signs were there, but no one could have suspected it. My poor little boy.
 
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