Biopsy/Surgery to do or not?

Cardinal87

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Hello

Thank you for accepting us! Ricky will be 15 on November 12th. I apologize in advance for the length of this. Looking back I have to say over the course of many years, Ricky’s off and on vomiting, and diarrhea was never really addressed and I am so mad at myself. Back in 2018 he was given metronidazole for a bought of diarrhea. I think around then he was diagnosed with constipation and he has been getting ¼ teaspoon of Miralax daily, he was not really given a special diet, we tried the Royal Canin GI high energy food, Ricky’s favorite food is Fancy Feast Medley’s and Friskies wet food. In May of this year my Mom mentioned Ricky’s hips looked thin so I addressed this with his primary and he was at 15.14 pounds (he was 15.12 on 3/19/20). Also maybe during this time, Ricky stopped waking me up during the night for a snack, he Always woke me up and I thought maybe it was because our 3rd feline Pepper was spending time in the bedroom and Ricky and Pepper do not get along and I keep them separated. He also chose a new spot to sleep (under a desk) and I thought is he hiding but he often finds different places to sleep (currently his new spot is under the fish tank) During his 6 month wellness exam on 7/8/20 he was at 15.04. I mentioned he vomited 6 times from 6/8-7/2/20 and nothing was really said. He was never diagnosed with IBD. On 8/31/20 he had some diarrhea and on 9/1/20 he was supposed to get his leukemia vaccine and he weighed 14.20, so the primary said maybe we should see an internal medicine doctor, we agreed to not give him the vaccine. I found an IM doctor an hour away that saw Ricky on 9/3/20. The results of the ultrasound were: 1) moderately large cystic structure associated with the liver adjacent to the stomach – rule out biliary cyst adenoma versus other 2) Bilaterally hyperechoic renal cortices with decreased corticomedullary definition – rule out age related renal degeneration versus other 3) Diffusely mildly thickened small intestinal wall with prominent muscularis layer – rule out inflammatory bowel disease (IBD) versus small cell intestinal lymphoma versus other 4) Mesenteric lymphadenopathy – rule out reactive lymphadenopathy versus metastatic neoplasia versus other.

Ricky was scheduled to meet with his Cardiologist on 9/10 and the Hospital kindly squeezed in a surgery consultation after that appointment so we did not have to take two 40 minute (one way) drives. (The cardiologist said there was no change from last year and he could have surgery – Side note in 2018 I thought he looked lethargic and rushed him to the ER, they said he was OK and his primary care doctor recommended we do a proBNP test which shown a high number, she recommended he see a cardiologist who did not see anything wrong in 2018, she recommended a follow up in 2019 and a new cardiologist also did not see anything and said Ricky should not be tested for proBNP anymore and if nothing changed in 2020 he would not need to be seen again)

It was pouring rain out when I spoke to the surgeon after the consultation and I could not hear her that well but my understanding was Ricky is a good candidate for the removal of the cyst and the biopsy of his intestines, liver and lymph nodes. She said due to there being multiple lesions to address Ricky could not have aspirations or endoscopes done. She said there is a risk of a serious complication of leakage of intestinal contents that can occur at the biopsy site. She said this is reported up to 20% but her experience was lower. She said if this happened a 2nd surgery would be needed and after the 2nd surgery the outcome was favorable. She said surgery is not needed right away but that surgery should be done within the next couple of weeks. I asked about the #2 item on the ultrasound (she did not even mention it) and said this could be early kidney disease. She said that Anesthesia can stress out the kidney’s and that a chronic kidney disease could become acute kidney disease. I asked her about Rickey’s age and she said age is Not a disease. She said I would receive her notes over the next few days and I received them on Saturday which I enclosed. She did not even mention the anesthesia potential problem in the notes which makes me wonder if there are other potential problems that I failed to ask about and she failed to mention thinking I knew about. Also Ricky has not ever been away from home before, it is my understanding he would be away the night before the surgery and the night of the surgery and maybe another day or more. Ricky is very nervous going to the Vet his palms get sweaty.

Our primary care doctors have said the decision to do the surgery is up to me they have not advised me either way, they just said to weigh the options and they will help with any decision. Their only advice was to not let Ricky eat any grass when outside or that we have grown inside (He loves to eat grass but then will vomit it up sometimes, it has been so hard to stop him from eating grass outside)

I want to do what is right for Ricky, what Ricky would want and not want I want. I play these mind games, if Ricky wakes me up then that means he wants the surgery. Also health care should not be about the cost but the cost for the surgery low end is $5k and high end $5,700.00, we are located in Connecticut.

So right now we are in limbo as I have been unable to decide if Ricky should get the cyst removed with the 3 biopsy’s done. It is my understanding that we should not start any therapy now and then decide to do the biopsy later as the results could be inclusive. After the 3 visits Ricky had diarrhea and vomiting and our primary care said environmental factors could contribute to IBD symptoms. (after fasting for the ultra sound on 9/3, on the night of 9/4 I heard his stomach gurgling for hours and finally he projectile vomited across the futon, and floor it was liquid and a little hair, I have never seen anything like that, it was very scary) I feel very pressured to make a decision right away so Ricky can start some kind of therapy and also the surgeon said a decision should be made within a few weeks while Ricky is doing well.

I have been reading and saving a lot of your posts to refer again to later. I would appreciate anyone’s input on why they decided to do the biopsy, risk factors they were advised of, age of their kitty, and if cancer was found did you do chemotherapy and how did your kitty handle Chemo and anyone that did not do the biopsies and why they did not and if they regretted either decision. And what your cost was. Also hoping to hear from anyone that had a liver mass removed and the outcome. (the liver lobectomy is $1,800 so that is why the cost is so high). Also, In reading some posts, it is my understanding that some of you did not do a biopsy but that your kitties’ treatment could involve chemotherapy drugs. The surgeon said chemotherapy drugs are not given if a cancer diagnosis is not proven, so I confused on how some kitties may be getting chemo drugs without having a cancer diagnosis. Any information on this topic would also be greatly appreciated.

Healthy Regards

Ricky and Maria

Ricky 14th bd 20191112_070533 (2).jpg
 

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fionasmom

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Such a beautiful boy.....orange boys are a favorite of mine. You have done a lot of research/ footwork and are to be commended on that. Try to move away from looking for a sign unless that is part of a spiritual belief in which you are highly invested and you would feel comfortable acting on the advice of that mental image. I am not saying this to be critical as I have been there and it does not help. I refused to let one of my dogs have an important surgery on April 1 because that is April Fool's Day and "I would have to be a fool to allow it on that day." It does not get you anywhere.

I can only hit and miss some of your questions. You are going to an IM but if your cat has surgery will it be at a full service referral hospital with all the bells and whistles in case they are needed? Given the age of the cat, I would want all possible outcomes to be covered and I am not trying to scare you. Ventilators ready to go, full time nursing assigned to Ricky round the clock for as long as he is hospitalized, etc.

As for intestinal lymphoma and the use of chlorambucil/leukeran without the requisite biospies, at least a couple of us have done this. More correctly I should say that daftcat75 daftcat75 followed this path for his Krista who recently passed on; he advised me to ask Chelsea's vet about this and she agreed that we could try it. That does not mean that every vet will go down that road easily.

My reasons for not having biopsies on Chelsea are/were that she is not easily handled, even at 10 years old, having been a feral, now a little closer to semi feral indoor only. We did reach a detente where she allows me to use a pill popper to administer her meds but I knew that I could never nurse her through anything that required great handling.

Maybe I should quit while I am ahead but the reason for my vigilance about surgery, especially in older animals, is that I did lose a dog years ago (prior medical conditions) due to anesthesia administered during the procedure. Anesthesia has been improved for animals and humans now, but it was the reason that a couple of my pets have been referred to a full service hospital.

As for cost, it seems that you understand that this will not be inexpensive. Your quotes seem in line with what I would receive out here as well in LA. Example: my GSD had his leg amputated due to melanoma for about $4000 (amputations have to be done correctly, but they are not the trickiest surgery) and took 6 immunotherapy vaccines ( called a vaccine but it is only used after you have cancer, not to prevent initial onset) for $1000 each.
 

daftcat75

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In Krista's case, she had several ultrasounds performed over her last few years. They always said, "thickening consistent with IBD or small cell lymphoma." A biopsy was always recommended to determine which. The rule of thumb that I heard and operated on was, "if she can gain or maintain weight, it's probably not cancer." So I always declined the biopsy, assumed IBD, and looked for the food triggers to control it through diet. It was only when she started having liquid stools late last year and diet or any of my other tricks were not helping. She was losing weight fast. So in to the vet she went for another U/S. Krista's vet first prescribed prednisilone. That helped a little but not enough. So I went back after two or three weeks and said, "can we try chemo since pred alone isn't working?" Krista's doc did not want to prescribe chemo without the cancer diagnosis that would require a biopsy. Now I was more adamant than ever to decline the biopsy because Krista was losing weight without any way to regain it. If we subject her to a surgery that comes with a recovery period, that's even more weight she'll lose with still no way to recover it. I went over my vet's head and asked to speak to owner and founder of the practice. Fortunately, he and I had a very similar mind on the matter. He gave me a talk about IBD and lymphoma and how they are probably the same disease on a spectrum from one end to the other. He also gave me the informed consent speech, "if I approve this, this still may not have the outcome you are hoping for." But in the end, I laid it out like this and he agreed with me:

Krista's options:
a. we do nothing and that's most certainly not going to help or end well
b. pred alone or more pred but we've already tried pred and that's not helping, not completely. if we continue on this path, it's more suffering and no recovery eventually leading to terminal wasting.
c. biopsy. comes with a recovery period. she will likely have a recovery period where more weight can be lost. the biopsy itself doesn't solve anything. it only gives us a thumbs or thumbs down for the next option
d. pred plus chemo. the chemo drug has very few side effects. this has the best option for remission and recovery.

Fortunately we both decided the drug was less risk than the diagnosis.

Krista's liquid stools cleared up almost completely, nearly overnight (one or two doses.) Unfortunately, I was using a trigger food to get her to take her pred because she does not comply with a pill shooter. It took us far too long and a surgery to drain an ear infection for us to achieve a remission when I swapped out the inflammatory fish flakes making up her nightly "pred bites" with a transdermal formulation. She finally achieved remission some five months after we started the chemo and six months after we started the pred. But it was too little too late. She had lost far too much weight getting here that she never did recover. A little more than a month ago, she had a bladder infection that proved too much for her. I want to believe that if we stuck with transdermal back when we tried it the first time, she would have achieved remission quicker. We may have been able to taper her steroids sooner. She may have been able to stage a recovery and who knows how much longer we might have had together?


Having said all of that, you should ask the specialist to review his options like we did with Krista.

You might ask:

a. is this IBD or small cell lymphoma or.... is there something else that could be that the biopsy will tell us? or is that the two options we're trying to decide one or the other
b. in other words, could this be large cell lymphoma?
c. if we started with chlorambucil, is there a chance that we're using the wrong drug?
d. what is the risks of using the wrong drug and will we be able to try a different chemo course if the first course proves ineffective?
e. is this approach of trying one course first, then the next riskier than the biopsy surgery?
f. if this was your cat, what would you do?

I'm glad you're working with a specialist. I'm trying to get past the regrets. But one that haunts me is that I didn't take her to an internal medicine specialist. I didn't believe there would be an added benefit over what I was reading online and consulting with her vets. In retrospect, I think an IM would have beat some sense into me over using fish flakes to wrap the pred and would have insisted we give transdermal or another compounding more of a chance. I also believe I would have received better guidance over the pred dose, frequency, and duration of treatment rather than the advice I was receiving from her non-specialist vets.
 
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Cardinal87

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Such a beautiful boy.....orange boys are a favorite of mine. You have done a lot of research/ footwork and are to be commended on that. Try to move away from looking for a sign unless that is part of a spiritual belief in which you are highly invested and you would feel comfortable acting on the advice of that mental image. I am not saying this to be critical as I have been there and it does not help. I refused to let one of my dogs have an important surgery on April 1 because that is April Fool's Day and "I would have to be a fool to allow it on that day." It does not get you anywhere.

I can only hit and miss some of your questions. You are going to an IM but if your cat has surgery will it be at a full service referral hospital with all the bells and whistles in case they are needed? Given the age of the cat, I would want all possible outcomes to be covered and I am not trying to scare you. Ventilators ready to go, full time nursing assigned to Ricky round the clock for as long as he is hospitalized, etc.

As for intestinal lymphoma and the use of chlorambucil/leukeran without the requisite biospies, at least a couple of us have done this. More correctly I should say that daftcat75 daftcat75 followed this path for his Krista who recently passed on; he advised me to ask Chelsea's vet about this and she agreed that we could try it. That does not mean that every vet will go down that road easily.

My reasons for not having biopsies on Chelsea are/were that she is not easily handled, even at 10 years old, having been a feral, now a little closer to semi feral indoor only. We did reach a detente where she allows me to use a pill popper to administer her meds but I knew that I could never nurse her through anything that required great handling.

Maybe I should quit while I am ahead but the reason for my vigilance about surgery, especially in older animals, is that I did lose a dog years ago (prior medical conditions) due to anesthesia administered during the procedure. Anesthesia has been improved for animals and humans now, but it was the reason that a couple of my pets have been referred to a full service hospital.

As for cost, it seems that you understand that this will not be inexpensive. Your quotes seem in line with what I would receive out here as well in LA. Example: my GSD had his leg amputated due to melanoma for about $4000 (amputations have to be done correctly, but they are not the trickiest surgery) and took 6 immunotherapy vaccines ( called a vaccine but it is only used after you have cancer, not to prevent initial onset) for $1000 each.
thank
Such a beautiful boy.....orange boys are a favorite of mine. You have done a lot of research/ footwork and are to be commended on that. Try to move away from looking for a sign unless that is part of a spiritual belief in which you are highly invested and you would feel comfortable acting on the advice of that mental image. I am not saying this to be critical as I have been there and it does not help. I refused to let one of my dogs have an important surgery on April 1 because that is April Fool's Day and "I would have to be a fool to allow it on that day." It does not get you anywhere.

I can only hit and miss some of your questions. You are going to an IM but if your cat has surgery will it be at a full service referral hospital with all the bells and whistles in case they are needed? Given the age of the cat, I would want all possible outcomes to be covered and I am not trying to scare you. Ventilators ready to go, full time nursing assigned to Ricky round the clock for as long as he is hospitalized, etc.

As for intestinal lymphoma and the use of chlorambucil/leukeran without the requisite biospies, at least a couple of us have done this. More correctly I should say that daftcat75 daftcat75 followed this path for his Krista who recently passed on; he advised me to ask Chelsea's vet about this and she agreed that we could try it. That does not mean that every vet will go down that road easily.

My reasons for not having biopsies on Chelsea are/were that she is not easily handled, even at 10 years old, having been a feral, now a little closer to semi feral indoor only. We did reach a detente where she allows me to use a pill popper to administer her meds but I knew that I could never nurse her through anything that required great handling.

Maybe I should quit while I am ahead but the reason for my vigilance about surgery, especially in older animals, is that I did lose a dog years ago (prior medical conditions) due to anesthesia administered during the procedure. Anesthesia has been improved for animals and humans now, but it was the reason that a couple of my pets have been referred to a full service hospital.

As for cost, it seems that you understand that this will not be inexpensive. Your quotes seem in line with what I would receive out here as well in LA. Example: my GSD had his leg amputated due to melanoma for about $4000 (amputations have to be done correctly, but they are not the trickiest surgery) and took 6 immunotherapy vaccines ( called a vaccine but it is only used after you have cancer, not to prevent initial onset) for $1000 each.
Thank
Such a beautiful boy.....orange boys are a favorite of mine. You have done a lot of research/ footwork and are to be commended on that. Try to move away from looking for a sign unless that is part of a spiritual belief in which you are highly invested and you would feel comfortable acting on the advice of that mental image. I am not saying this to be critical as I have been there and it does not help. I refused to let one of my dogs have an important surgery on April 1 because that is April Fool's Day and "I would have to be a fool to allow it on that day." It does not get you anywhere.

I can only hit and miss some of your questions. You are going to an IM but if your cat has surgery will it be at a full service referral hospital with all the bells and whistles in case they are needed? Given the age of the cat, I would want all possible outcomes to be covered and I am not trying to scare you. Ventilators ready to go, full time nursing assigned to Ricky round the clock for as long as he is hospitalized, etc.

As for intestinal lymphoma and the use of chlorambucil/leukeran without the requisite biospies, at least a couple of us have done this. More correctly I should say that daftcat75 daftcat75 followed this path for his Krista who recently passed on; he advised me to ask Chelsea's vet about this and she agreed that we could try it. That does not mean that every vet will go down that road easily.

My reasons for not having biopsies on Chelsea are/were that she is not easily handled, even at 10 years old, having been a feral, now a little closer to semi feral indoor only. We did reach a detente where she allows me to use a pill popper to administer her meds but I knew that I could never nurse her through anything that required great handling.

Maybe I should quit while I am ahead but the reason for my vigilance about surgery, especially in older animals, is that I did lose a dog years ago (prior medical conditions) due to anesthesia administered during the procedure. Anesthesia has been improved for animals and humans now, but it was the reason that a couple of my pets have been referred to a full service hospital.

As for cost, it seems that you understand that this will not be inexpensive. Your quotes seem in line with what I would receive out here as well in LA. Example: my GSD had his leg amputated due to melanoma for about $4000 (amputations have to be done correctly, but they are not the trickiest surgery) and took 6 immunotherapy vaccines ( called a vaccine but it is only used after you have cancer, not to prevent initial onset) for $1000 each.
Thank you for the reply fionasmom
 
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Cardinal87

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In Krista's case, she had several ultrasounds performed over her last few years. They always said, "thickening consistent with IBD or small cell lymphoma." A biopsy was always recommended to determine which. The rule of thumb that I heard and operated on was, "if she can gain or maintain weight, it's probably not cancer." So I always declined the biopsy, assumed IBD, and looked for the food triggers to control it through diet. It was only when she started having liquid stools late last year and diet or any of my other tricks were not helping. She was losing weight fast. So in to the vet she went for another U/S. Krista's vet first prescribed prednisilone. That helped a little but not enough. So I went back after two or three weeks and said, "can we try chemo since pred alone isn't working?" Krista's doc did not want to prescribe chemo without the cancer diagnosis that would require a biopsy. Now I was more adamant than ever to decline the biopsy because Krista was losing weight without any way to regain it. If we subject her to a surgery that comes with a recovery period, that's even more weight she'll lose with still no way to recover it. I went over my vet's head and asked to speak to owner and founder of the practice. Fortunately, he and I had a very similar mind on the matter. He gave me a talk about IBD and lymphoma and how they are probably the same disease on a spectrum from one end to the other. He also gave me the informed consent speech, "if I approve this, this still may not have the outcome you are hoping for." But in the end, I laid it out like this and he agreed with me:

Krista's options:
a. we do nothing and that's most certainly not going to help or end well
b. pred alone or more pred but we've already tried pred and that's not helping, not completely. if we continue on this path, it's more suffering and no recovery eventually leading to terminal wasting.
c. biopsy. comes with a recovery period. she will likely have a recovery period where more weight can be lost. the biopsy itself doesn't solve anything. it only gives us a thumbs or thumbs down for the next option
d. pred plus chemo. the chemo drug has very few side effects. this has the best option for remission and recovery.

Fortunately we both decided the drug was less risk than the diagnosis.

Krista's liquid stools cleared up almost completely, nearly overnight (one or two doses.) Unfortunately, I was using a trigger food to get her to take her pred because she does not comply with a pill shooter. It took us far too long and a surgery to drain an ear infection for us to achieve a remission when I swapped out the inflammatory fish flakes making up her nightly "pred bites" with a transdermal formulation. She finally achieved remission some five months after we started the chemo and six months after we started the pred. But it was too little too late. She had lost far too much weight getting here that she never did recover. A little more than a month ago, she had a bladder infection that proved too much for her. I want to believe that if we stuck with transdermal back when we tried it the first time, she would have achieved remission quicker. We may have been able to taper her steroids sooner. She may have been able to stage a recovery and who knows how much longer we might have had together?


Having said all of that, you should ask the specialist to review his options like we did with Krista.

You might ask:

a. is this IBD or small cell lymphoma or.... is there something else that could be that the biopsy will tell us? or is that the two options we're trying to decide one or the other
b. in other words, could this be large cell lymphoma?
c. if we started with chlorambucil, is there a chance that we're using the wrong drug?
d. what is the risks of using the wrong drug and will we be able to try a different chemo course if the first course proves ineffective?
e. is this approach of trying one course first, then the next riskier than the biopsy surgery?
f. if this was your cat, what would you do?

I'm glad you're working with a specialist. I'm trying to get past the regrets. But one that haunts me is that I didn't take her to an internal medicine specialist. I didn't believe there would be an added benefit over what I was reading online and consulting with her vets. In retrospect, I think an IM would have beat some sense into me over using fish flakes to wrap the pred and would have insisted we give transdermal or another compounding more of a chance. I also believe I would have received better guidance over the pred dose, frequency, and duration of treatment rather than the advice I was receiving from her non-specialist vets.
Thank you for the reply daftcat75 and I am very sorry to hear about Krista, I enclosed a poem that I am sure you have read but just in case you have not it has brought me comfort in the past
 

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SnugglesAnn

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Oh, he looks so much like my baby Oliver that I lost a month ago. Orange kitties really are sweethearts. I really don't have any good advice here, just wanted to let you know that I will be praying for you guys. Hoping everything works out. ❤❤
 
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