Getting chemo with inconclusive lymphoma diagnosis

Wrobel

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Hi, I saw a previous post you made a few years ago and it said that your kitty had an inconclusive lymphoma diagnosis but was still able to receive chemo. Can you give me some information on how you were able to make that happen? None of the vets in my area are willing to treat without a concrete diagnosis. I'm in NJ, maybe your vet is not too far? Thank you! daftcat75 daftcat75

Thanks for answering. I've had kitties pass on previously so I know how heartbreaking it is.
 
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fionasmom

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I was also in the same position and it was daftcat75 daftcat75 who advised me to approach the vet about the use of chlorambucil without a conclusive diagnosis. I will, of course, let him tell his own story.

What you are encountering is not sadly unexpected depending on the vet and hospital. My cat vet is quite accommodating and was open to the idea in part because Chelsea was a former feral, still tricky to handle, and I was concerned about invasive procedures and follow up.
 

daftcat75

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I know I have already typed this story a number of times. Thankfully, I used the phrase "informed consent" in nearly every post. That made it easy to find them.

I think this one says it all and says it best. I will be happy to answer questions after you have read this one. (Not the whole thread. Just the linked post.)
Biopsy/Surgery to do or not?

Short version: Make certain you have ruled out everything else you can reasonably rule out. Then you will have an "informed consent" discussion with your vet saying, you understand you are trying a drug without a diagnosis--and that it may not help if your thesis (that this is cancer) is wrong. But that given the options, the drug likely carries fewer risks than obtaining the diagnosis first.
 
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Wrobel

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I was also in the same position and it was daftcat75 daftcat75 who advised me to approach the vet about the use of chlorambucil without a conclusive diagnosis. I will, of course, let him tell his own story.

What you are encountering is not sadly unexpected depending on the vet and hospital. My cat vet is quite accommodating and was open to the idea in part because Chelsea was a former feral, still tricky to handle, and I was concerned about invasive procedures and follow up.
Thank you! It's good to know that there are accommodating vets out there.
 
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Wrobel

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I know I have already typed this story a number of times. Thankfully, I used the phrase "informed consent" in nearly every post. That made it easy to find them.

I think this one says it all and says it best. I will be happy to answer questions after you have read this one. (Not the whole thread. Just the linked post.)
Biopsy/Surgery to do or not?

Short version: Make certain you have ruled out everything else you can reasonably rule out. Then you will have an "informed consent" discussion with your vet saying, you understand you are trying a drug without a diagnosis--and that it may not help if your thesis (that this is cancer) is wrong. But that given the options, the drug likely carries fewer risks than obtaining the diagnosis first.
Thank you so much! This is very helpful. I'm sorry about your kitty. It's a hard journey :(. Yes, the diagnostic surgery to remove the tumor is life threatening but they still want to push it on us instead of trying offering to try the chemo. I will ask my regular vet's opinion. This was the oncology surgeon pushing the large surgery that would require the kitty to get a feeding tube. Thanks so much again!
 

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Thank you so much! This is very helpful. I'm sorry about your kitty. It's a hard journey :(. Yes, the diagnostic surgery to remove the tumor is life threatening but they still want to push it on us instead of trying offering to try the chemo. I will ask my regular vet's opinion. This was the oncology surgeon pushing the large surgery that would require the kitty to get a feeding tube. Thanks so much again!
A tumor is a whole other story. Chemo is not likely to help much without removing the tumor first. This is different than Krista (and Chelsea.) In those cases, it was small cell lymphoma. The difference in treatment between IBD and small cell lymphoma is one drug: chlorambucil. I don't have experience with large cell lymphoma. But my understanding is that large cell lymphoma (that which produces a tumor rather than diffuse inflammation like SCL) is more malignant, carries more risk of spreading to other tissues and organs, and has a poor prognosis. This is definitely a conversation to have with the oncology surgeon. But it's likely in this case, that chemo without removing the tumor may be like trying to put out a house fire with a water pistol. I would not be scared of the feeding tube. Krista had one for a different reason. I will tell you that I probably minded it more than she did. And it definitely saved her life. If this was my cat (and I definitely recommend asking the surgeon what he would recommend if it was his cat), I would ask about prognosis and outcomes and how much more life and quality of life are we looking at if we removed the tumor vs pred alone or palliative care. You can also ask the onc. if chemo without removal would be of any value. In other words, my advice with Krista's case may not apply here because we're talking about different cancers with different progressions and different outcomes.
 
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Wrobel

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A tumor is a whole other story. Chemo is not likely to help much without removing the tumor first. This is different than Krista (and Chelsea.) In those cases, it was small cell lymphoma. The difference in treatment between IBD and small cell lymphoma is one drug: chlorambucil. I don't have experience with large cell lymphoma. But my understanding is that large cell lymphoma (that which produces a tumor rather than diffuse inflammation like SCL) is more malignant, carries more risk of spreading to other tissues and organs, and has a poor prognosis. This is definitely a conversation to have with the oncology surgeon. But it's likely in this case, that chemo without removing the tumor may be like trying to put out a house fire with a water pistol. I would not be scared of the feeding tube. Krista had one for a different reason. I will tell you that I probably minded it more than she did. And it definitely saved her life. If this was my cat (and I definitely recommend asking the surgeon what he would recommend if it was his cat), I would ask about prognosis and outcomes and how much more life and quality of life are we looking at if we removed the tumor vs pred alone or palliative care. You can also ask the onc. if chemo without removal would be of any value. In other words, my advice with Krista's case may not apply here because we're talking about different cancers with different progressions and different outcomes.
Thank you! They think it's a tumor but they are not completely sure. It's just a large thickening on the ultrasound so they are suspecting that it's a mass but they took a few fine needle samples and all came back inconclusive. It's crazy because they don't even let you talk to that oncologist that prescribes the chemo without a concrete diagnosis, only the surgeon who suggested the surgery but said she can't promise the intestines will heal b/c of inflammation - which sounds alarming to me while the cat is still enjoying life and I'm scared the surgery could possibly end it faster than the steroids if they mess up or she won't heal :(. It's so scary to make the wrong choice.
 

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Thank you! They think it's a tumor but they are not completely sure. It's just a large thickening on the ultrasound so they are suspecting that it's a mass but they took a few fine needle samples and all came back inconclusive. It's crazy because they don't even let you talk to that oncologist that prescribes the chemo without a concrete diagnosis, only the surgeon who suggested the surgery but said she can't promise the intestines will heal b/c of inflammation - which sounds alarming to me while the cat is still enjoying life and I'm scared the surgery could possibly end it faster than the steroids if they mess up or she won't heal :(. It's so scary to make the wrong choice.
What are her other symptoms? Vomiting? Diarrhea? Is she able to maintain or gain weight? Or has it been a relentless freefall? For me, that was the biggest differential between IBD and lymphoma. When Krista's weight loss became rapid and unrelenting despite eating more than enough calories, that's when I knew we were dealing with a different animal than her previously well-controlled IBD. That was also the biggest risk factor in putting her through any surgery. We needed to stop the weight loss first, not cause more.

I'm sorry you and her are going through this. I think the best thing to do would be to schedule some time with someone who can sit down and talk with you. It can be hard to talk about this. But I think you may need to divide a sheet four ways and talk about options and outcomes. Those four options might be:
a. doing nothing. e.g. palliative care
b. pred alone (I presume you may already be doing this option.)
c. surgery
d. chemo without surgery ... except if they aren't certain whether it's a mass or diffuse inflammation, they may end up choosing the wrong chemo drug which would bring you another option, chemo with the wrong drug

You might ask if you can do an A/B or in this case, an A/B/C treatment plan. Plan A would be pred alone. Agree on how long to do this before proceeding to plan B: chemo drug 1. Try chemo drug 1 for an agreed amount of time before switching to plan C: chemo drug 2. A lot of general vets seem to "pred and pray" and when that doesn't work, they throw more pred at it. This is why it's a good idea to consult with specialists. But specialists have their own decision trees and preferred diagnostics and may be less willing to go off-road. So you may have to include "more pred" in your options discussion. But also try to make agreements when to say pred alone isn't working, and it's time to move to the next plan.

Specialists being specialists, you may just have to shop her case around to a general vet who would be willing to work with you even without the preferred diagnostics or surgery. You'll have to bring her down to any new vet she sees. None can prescribe for a patient they haven't seen. But you can hopefully carry or transfer records in and save on repeat diagnostics.
 
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Wrobel

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Thank you for the detailed suggestions.. very helpful. We noticed that she was eating less... she's a kibble mostly kitty that doesn't love wet food so we thought maybe it was a dental issue. She was pretty big so we didn't notice the weight loss right away. She would vomit from time to time like once or twice a week but she's always done that and never got diagnosed with anything. In hindsight we think she just have had undiagnosed ibd for years. After ruling out the tooth issue, vet suggested to switch kibble so we tried that for two weeks and she ate a little more but then looked super lethargic one day and so i took her to the ER and they said she was dehydrated and did all tests blood work was good but ultrasound found the 4cm of thickening which might be a tumor plus other questionable nodules that are smal
and can be benign in a 13 year old kitty. She doesn't have diarrhea, it seems like mostly nausea and lack of appetite. She went down from 15lbs to 12.5 and now lost another pound in the last 3 weeks but she's not eating enough calories although she eats small bites throughout the day. She's not on predisone yet in case we want to do the surgery but she's on miratraz and i give her small doses of cbd. She's still playful and enjoys spending time outside on the porch.
 

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I would get a baby scale to weigh her no more than once a week for everyone's sanity.
Amazon.com

I place a towel in the basket so Betty, who stubbornly refuses nail trims, doesn't have nails against plastic. I call her over with the treat bag and place a treat in one end of the basket. If I have to, I lift her butt skyward and deposit it in the basket so I'm not just weighing her front paws. She knows the routine now and has had her butt lifted skyward enough times that she will climb all the way into the basket before she eats the treat. While she's eating the treat, the scale dances around until it reaches its result--usually before she finishes the treat. I have occasionally had to resort to taring the scale while she was on it and then grabbing the negative weight after she left.

Weigh your kitty (what's her name?) once a week. I do Sunday mornings with Betty. If yours isn't eating enough, then I also recommend a food journal to keep track of daily and weekly calories. You cannot manage what you cannot measure.

If you haven't tried pred yet, then that's still an option open to you. Yes, you probably close the door on the surgery option. But I think you're leaning that way anyway. What I would like to see is shoring up her appetite and whether her weight stabilizes. Whether she can maintain or even gain weight is most important to me as to what the outcomes may look like. As I've understood it, cancer eats calories. So if you stabilize her eating and she's still losing weight, that seems like a pretty definitive determinant there (assuming you have ruled out other sources of weight loss like hyperthyroidism.) Pred would likely shore up her appetite. And then some. If she's not taking anything for nausea, you could ask for ondansetron. Betty gets this twice a day. I was able to wean her off steroids. But whenever I tried to skip an ondansetron dose, intentionally or otherwise, she seems to eat better and easier with it. Some cats do better with the mirtazapine tablets rather than the gel. Yes, it can be a more intense experience for everyone. They don't call it meowzapine without reason. But if you wanted a non-pred option to see if you can restore her eating, that would be worth it, yes? I found that with both Krista and Betty, the pills worked a whole lot better. As for the meows, they both seemed to be content to chirp it out in my lap while I gently stroked them through it until the big rush passed. Then they would inevitably tear into the food and bully that plate around until there wasn't even a crumb hiding underneath it.

It can also be easier to track your cat's eating and it's better for her hydration if she eats more wet food. You might ask for a sample of different prescription foods. Most of them seem like a shopping list for garbage. But cats seem to like them. At this point, that's the most important thing. It's better to eat well at McDonald's than to starve at Whole Foods. Betty would recommend Hills I/D (their digestive stew or pate) with just a little Hills A/D pate mixed in for a richer flavor. Whenever Betty's appetite has gone low, A/D has been a reliable food to bring her to eating. But it's also been too rich for her to eat it alone. During fussier times, it may be a 50/50 mix. These days, she gets a 2:1 (I/D : A/D) mix. Betty also gets a little CBD. I cut up a couple of kibbles in a pill cutter and drop the CBD on those. Then atop those, I sprinkle a few more ground pieces of kibble. This way she still gets the taste of kibble and still gets a few pieces. But the majority of her meal is wet food that's weighed on a food scale at every meal. I soak the cans from the fridge in a hot water bath for several minutes so that she doesn't get fridge cold food. This also seems to be a difference maker with Betty who very likely does have dental issues in addition to her sometimes sensitive tummy.
 
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silent meowlook

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My own cat has a space occupying lesion (mass) seen on ultrasound in 2021. The ultrasound is the only diagnostic I did. My cat would not be a surgical or anesthetic patient. To high risk. She has been on Prednisolone and Chlorambucil (Chemo) since then.

I have seen chemotherapy done to reduce a tumor to make it easier to remove as well.,
 
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Wrobel

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I would get a baby scale to weigh her no more than once a week for everyone's sanity.
Amazon.com

I place a towel in the basket so Betty, who stubbornly refuses nail trims, doesn't have nails against plastic. I call her over with the treat bag and place a treat in one end of the basket. If I have to, I lift her butt skyward and deposit it in the basket so I'm not just weighing her front paws. She knows the routine now and has had her butt lifted skyward enough times that she will climb all the way into the basket before she eats the treat. While she's eating the treat, the scale dances around until it reaches its result--usually before she finishes the treat. I have occasionally had to resort to taring the scale while she was on it and then grabbing the negative weight after she left.

Weigh your kitty (what's her name?) once a week. I do Sunday mornings with Betty. If yours isn't eating enough, then I also recommend a food journal to keep track of daily and weekly calories. You cannot manage what you cannot measure.

If you haven't tried pred yet, then that's still an option open to you. Yes, you probably close the door on the surgery option. But I think you're leaning that way anyway. What I would like to see is shoring up her appetite and whether her weight stabilizes. Whether she can maintain or even gain weight is most important to me as to what the outcomes may look like. As I've understood it, cancer eats calories. So if you stabilize her eating and she's still losing weight, that seems like a pretty definitive determinant there (assuming you have ruled out other sources of weight loss like hyperthyroidism.) Pred would likely shore up her appetite. And then some. If she's not taking anything for nausea, you could ask for ondansetron. Betty gets this twice a day. I was able to wean her off steroids. But whenever I tried to skip an ondansetron dose, intentionally or otherwise, she seems to eat better and easier with it. Some cats do better with the mirtazapine tablets rather than the gel. Yes, it can be a more intense experience for everyone. They don't call it meowzapine without reason. But if you wanted a non-pred option to see if you can restore her eating, that would be worth it, yes? I found that with both Krista and Betty, the pills worked a whole lot better. As for the meows, they both seemed to be content to chirp it out in my lap while I gently stroked them through it until the big rush passed. Then they would inevitably tear into the food and bully that plate around until there wasn't even a crumb hiding underneath it.

It can also be easier to track your cat's eating and it's better for her hydration if she eats more wet food. You might ask for a sample of different prescription foods. Most of them seem like a shopping list for garbage. But cats seem to like them. At this point, that's the most important thing. It's better to eat well at McDonald's than to starve at Whole Foods. Betty would recommend Hills I/D (their digestive stew or pate) with just a little Hills A/D pate mixed in for a richer flavor. Whenever Betty's appetite has gone low, A/D has been a reliable food to bring her to eating. But it's also been too rich for her to eat it alone. During fussier times, it may be a 50/50 mix. These days, she gets a 2:1 (I/D : A/D) mix. Betty also gets a little CBD. I cut up a couple of kibbles in a pill cutter and drop the CBD on those. Then atop those, I sprinkle a few more ground pieces of kibble. This way she still gets the taste of kibble and still gets a few pieces. But the majority of her meal is wet food that's weighed on a food scale at every meal. I soak the cans from the fridge in a hot water bath for several minutes so that she doesn't get fridge cold food. This also seems to be a difference maker with Betty who very likely does have dental issues in addition to her sometimes sensitive tummy.
Thank you again for sharing your wealth of information on helping my cat. Her name is Wrobel :). Your Betty is in good hands with such a knowledgeable pet parent as you! I will give your ideas a try! Haha yes my vet gave us some of those prescription foods to try and the ingredients do seem like a strange mix of garbage. So far, Wrobel has not been into any of them, but I will try mixing them with warm water today and see how it goes. Will also order the scale. I'm also wondering if there are some blood tests that can point us in the right direction with the diagnosis. I know there are lots of blood markers that they test on humans. I'm curious about this, but it's hard to discover the answers when they don't even let us meet with the actual oncologist. Thanks again for all your great tips :).
 

daftcat75

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Thank you again for sharing your wealth of information on helping my cat. Her name is Wrobel :). Your Betty is in good hands with such a knowledgeable pet parent as you! I will give your ideas a try! Haha yes my vet gave us some of those prescription foods to try and the ingredients do seem like a strange mix of garbage. So far, Wrobel has not been into any of them, but I will try mixing them with warm water today and see how it goes. Will also order the scale. I'm also wondering if there are some blood tests that can point us in the right direction with the diagnosis. I know there are lots of blood markers that they test on humans. I'm curious about this, but it's hard to discover the answers when they don't even let us meet with the actual oncologist. Thanks again for all your great tips :).
Hills A/D is popular. That might be the one you start with and then mix in the others if that's a hit. It's high in calories and meant to be highly palatable as an emergency food to get cats (and dogs) eating again. In other words, it's perfect here. But I find with Betty that she doesn't eat enough of it on her own. So I mix it with the I/D pate. I don't add warm water to the food because it makes it soggier and Betty doesn't eat when the food is served. Sometimes she does like second dinner. But most times, she is either still sleeping (lunch) or needs time for her meds to kick in (breakfast and dinner) before she will hit the plate. Instead, I keep the cans covered with their plastic lids to keep water from getting in them. Then I have two shallow dishes that I place each can into and weight the two of them down with a plate. Then I let hot water trickle onto the plate and into the dishes to keep the water bath hot even while the cold food is trying to cool the water down. Wasteful? Probably. But less than I put into my Bissell when I have to clean a sour stomach barf up because she didn't eat within a certain number of hours.

I'm told there is a blood test that can be an indicator of lymphoma. But it's also not reliable. It has false negatives. So you can ask about it. You can get her tested. But if it comes back negative, that doesn't mean she doesn't have lymphoma. I believe the positives can be trusted though and that's why it's sometimes still ordered despite it's subpar accuracy. I don't remember it's name though.
 

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This is some information about blood markers in cats. I am in no way suggesting that you do this without thoroughly consulting with your vet regarding reliability, etc.

Human blood marker tests are debated as well because of the rate of false negative and false positive results.

Companies which sell blood marker tests, or circulating tumor DNA tests, tend to heavily market their product.

GI Lymphoma Panel – VDI Laboratory, LLC
How is Feline Lymphoma Diagnosed? What to Expect from Your Vet When Your Cat has Certain Symptoms – ImpriMed

These may or may not be the companies that @daftcat was thinking of. Your vet should know or be able to find out the rates of accuracy that these companies are recording...or any other company which offers marker tests.
 

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Here’s a picture of the hot water bath I do for Betty’s meals. It’s just me with no spouse or kids. Without kids wasting water, I don’t feel bad about the little I use for Betty’s food. Maybe I’ll pick up and try a Jettle (hot water kettle that heats water quickly) later this year. That small stream runs for a few minutes since the cold of the cans wants to cool the bath. The running hot water asks the can to catch up to the water temperature rather than the other way around. Yes I was a science major in school. 😹👍
IMG_0274.jpeg
The can’s inevitably lose their labels in the bath. So I rely on the color of the lids. I use yellow for A/D and white for I/D. Though I also know what they look and smell like by now.
 
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Wrobel

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Hills A/D is popular. That might be the one you start with and then mix in the others if that's a hit. It's high in calories and meant to be highly palatable as an emergency food to get cats (and dogs) eating again. In other words, it's perfect here. But I find with Betty that she doesn't eat enough of it on her own. So I mix it with the I/D pate. I don't add warm water to the food because it makes it soggier and Betty doesn't eat when the food is served. Sometimes she does like second dinner. But most times, she is either still sleeping (lunch) or needs time for her meds to kick in (breakfast and dinner) before she will hit the plate. Instead, I keep the cans covered with their plastic lids to keep water from getting in them. Then I have two shallow dishes that I place each can into and weight the two of them down with a plate. Then I let hot water trickle onto the plate and into the dishes to keep the water bath hot even while the cold food is trying to cool the water down. Wasteful? Probably. But less than I put into my Bissell when I have to clean a sour stomach barf up because she didn't eat within a certain number of hours.

I'm told there is a blood test that can be an indicator of lymphoma. But it's also not reliable. It has false negatives. So you can ask about it. You can get her tested. But if it comes back negative, that doesn't mean she doesn't have lymphoma. I believe the positives can be trusted though and that's why it's sometimes still ordered despite it's subpar accuracy. I don't remember it's name though.
Thank you so much! I will ask the vet about that food. I called my regular vet today but he was in surgery all day so will get back to us tomorrow. Also called another oncologist and the receptionist said she might be able to get me a virtual appointment without a confirmed diagnosis, but she can't promise the doc will help us out. So, waiting for regular vet first and will see. Wrobel has been in good spirits for most of the day, even asked for snacks. She went outside on the steps and tried to catch some birds that were flying in the distance. Thank you again 🙏❤
 
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