Mandibulectomy experience and expert doctors in Los Angeles?

[botolo]

Hello,

My beloved cat Holly might have an oral cancer (we are waiting for the results of the biopsy). I am trying to collect as much information as possible so that I am ready to move forward when the biopsy results come back.

Has anyone of you have experience with mandibulectomy? If so, how was your experience?

Also, do you have experience with any doctor in the Los Angeles area with expertise on this procedure?

 

[Caspers Human]

I'm so sorry to hear that your cat is so sick!

I'd need to know more about your cat before I would be able to give a cogent answer.

How old? General health? Any past medical problems?

How bad is the (possible) cancer as far as you already know? How did you find out about it? How far along do you (and the vets) think it might be? Are the vets already suggesting mandibulectomy? Or do they say the surgery MIGHT be necessary?

What is your vet's prognosis?

How well do you think your cat might tolerate such a surgery? If surgery is necessary, how well do you think your cat can recover?

There's a continuum, here. We need to try and place your cat on that scale in order to make a good decision. If your cat is young and resilient, I would be more inclined to agree with surgery but, if the cat is elderly and in poor health, I'd probably suggest palliative care until the time comes.

Also something to think about... What about YOU?

How well could you tolerate having to care for a cat that has cancer and has undergone such a major surgery?
If chemotherapy is needed, you will probably be the one to give meds to the cat on a regular, if not daily, basis. Can you do handle that?
Don't forget. Frequent trips to the vet will likely be necessary, at least in the beginning. How will you cope with having to corral a cat so much?

What about your finances? Can you afford it? Do you have pet insurance?

This is a really complicated issue! We can offer our advice and support but it's you who will have to be the one to say, "Final Answer."

My fingers are crossed for you!
Sending good vibes for you!

Our thoughts and prayers are with you!

Casper sends his love, too!

 

[botolo]

Thank you for the reply. Holly is a 9 years old very active and happy cat. Her blood work done recently is perfect. She never had any health issues before.

I noticed a few days ago that she was drooling a little bit and that she was eating her treats and kibbles without chewing. I assumed a dental issue and brought her to the vet. The vet found a mass under the tongue and suspected cancer. She also did x-rays which showed a degradation of the left mandible. Two days later I brought her to a vet dentist who performed CT scan and biopsy. CT scan confirmed degeneration of the left mandible and she has a bump right under her chin at the very front of her mouth. We are waiting for biopsy results.

The dentist told me that in general cats do not tolerate mandibulectomy well and that he would most likely suggest to go to an oncologist for further evaluation.

I am writing here because after reading tons of articles online, it looks like this idea of mandibulectomy not good for cats is somehow old news. I found several scientific articles more recent that seem to confirm that mandibulectomy can be an option and that many cats tolerate it very well. I also emailed one of the doctors who wrote these papers, he reviewed Holly’s CT scan and told me she could be a good candidate for it.

I have already scheduled visits with another dentist at a big VCA hospital here in Los Angeles and another visit with a big oncology / radiation center in my city. They all told me that we need to wait for the biopsy for further evaluation.

Holly now is doing fine. The only issue is that it looks like she has problems pulling her tongue out to grab food. It is weird because I see her moving her tongue very well after eating, licking her face all around. But when she goes down on the bowl, you can tell that she has problems getting the food.

She is currently under buprenorphine (one shot under the skin twice a day) and antibiotics.

I have no problems taking care of her and bringing her to the vet as much as needed. I have no money problems because I have a fantastic insurance that covers 90% of everything. My other cat just went through months of hospitalizations and finally surgery to solve an issue with his kidney. I had to pay $40k in advance but the insurance covered almost everything a few days later.

 

[fionasmom]

I think that you are on the right track. You have the right consultations scheduled and are gathering information. I have been asking around to see if there is one doctor in the greater LA area who is considered to be the gold standard for this surgery and have not come up with a name. That does not mean that there are not entirely competent vets who could do this, just not one name coming up.

This doctor who wrote this article is at MSPCA Angell. I wonder if he knows anyone locally if you were to contact him. The article is about the procedure in dogs, but he still must have experience in general in the procedure.

Canine Mandibulectomy and Maxillectomy

 

[fionasmom]

I wonder if UC Davis could give you a lead.

Frank J M Verstraete

 

[botolo]

Thank you so much for checking. So far one name who came up more than once during my investigation is this one:

Arathi Vinayak

I have an appointment with her on Monday.

I also have an appointment much closer to me with this doctor tomorrow:

Margaret Smith

 

[fionasmom]

I have had friends whose animals were treated at both of those facilities.....successfully and against some odds. Not oral tumors, but they each have top notch doctors and staff. Glad that you have found some doctors locally, even though one means a drive down the freeway. Please let us know what you are told and good luck!

 

[botolo]

Hello,

This morning I talked to Dr. Smith at VCA West Los Angeles. She thinks the tumor is too extended to do mandibulectomy and she recommends palliative care, unfortunately. I still have the appointment with Dr. Vinayak on Monday.

 

[fionasmom]

I am sorry to read that. Keep the next appointment as you have gone this far and see if you get the same answer. If Dr. Vinayak says that she can do the surgery, ask her to respond to the reasons you were given by Dr. Smith for not doing it. I know that you were not expecting this news.

 

[botolo]

I was able to secure an appointment with Dr. Carey at Access in Culver City tomorrow morning. I look forward to hearing what she says.

 

[fionasmom]

Please keep us posted. By Monday you should have some consensus of opinions, at the least. Talking to three surgeons is probably a good idea.

 

[botolo]

Here is an update. Today Holly has been visited by the head of the surgery department at Access in Culver City. Dr. Carey has experience with this procedure and she was very well aware of all the recent studies I have found online. She says that Holly would need a radical mandibulectomy, that some cats do well after it, some cats don't and that unfortunately we don't have a crystal ball to know where Holly will be.

Right now the doctor is running some more tests to understand the extension of the disease (chest x-ray and abdominal ultrasound), and she will talk to the radiation oncologist on site.

I have also talked to another surgeon with expertise on this and she thinks that having good margins would mean also removing part of the tongue but that would affect quality of life a lot (I would not do it).

So right now I am torn...

 

[fionasmom]

Yes, you are probably quite upset by all this. I do believe that Dr. Carey is being very thorough and logical. Knowing the full extent of the disease is so important to your decision and the outcome in the long term. I would continue with any appointment which is already scheduled, in person or distanced, so that you have several opinions. If nothing else, this will remove all gray area/second guessing. I am sorry that you are not getting any hopeful (for the procedure) news.

 

[botolo]

Here I am with an update. Holly has been seen by Dr. Carey at Access in Culver City. She is incredibly knowledgeable about this procedure, she was very familiar with all the most recent papers on the topic and has performed this procedure on cats a few times already.

She immediately did additional testing on Holly to make sure that she is healthy (apart from the cancer). Chest X-ray came back normal and abdominal ultrasound came back normal.

She has examined the CT scan and believes we can do radical mandibulectomy with good margins. She warned me that some cats don’t go back eating on their own and that it’s difficult to know if Holly will be one of them.

One concern I heard from other doctors is that surgery may require removal of the tongue. Dr. Carey thinks this may not be needed and we both agree that this is a line we would not cross.

I have a couple of days to decide how to move forward. The plan could be to do surgery this Monday. If during surgery the doctor feels that the tongue should be removed, we will most likely euthanize Holly while she is under anesthesia (hopefully hopefully hopefully not).

I am incredibly confused right now on how to proceed. On one side if I don’t do anything, Holly will die in the next few days/weeks. If I do surgery, I am giving her a shot. If during surgery, we realize the tongue needs to go, then Holly will die peacefully as she would do anyway if I don’t do anything. If surgery goes well, it will then be a waiting game to see if the cancer comes back and if she goes back to eating.

 

[fionasmom]

Despite your clear distress that this has happened to Holly at all, you are being extremely clear thinking about the options. That is huge, and I hope that you know that whatever happens, you absolutely gave Holly the best chance that she could have had and that many pet owners would not have even considered going further than the original diagnosis.

No one can tell you what to do, but only offer opinions. If you are inclined to proceed, then having the surgery very quickly is the right thing to do. If it came down to letting Holly go because this was more extensive than you hoped, allowing her to pass peacefully under anesthesia is the kindest thing to do. It will be hard on you, but eleventh hour dramatics like waking her up so that you can say good bye are not in her best interests.

If you do the surgery, and you have been given some hopeful information and originally seemed inclined to go forward (nothing wrong with having changed your mind though), you will have to approach the recovery as possibly something tentative and something that will require assistance for Holly, maybe for a long time. Hopefully, Holly would return to eating, make a comfortable recovery, and have some quality time given that she is only 9. That certainly all could happen.

While it is clear that you have Holly's best interests at heart, it might be useful to ask yourself what you could live with the easiest...doing the surgery and possibly having some complications (or not), or letting Holly go now. Either choice is entirely respectable and ethical, so it is not like one of them is wrong or harmful. But which one would give you the greatest sense of having honored Holly?

 

[botolo]

Thank you very much for the wonderful wonderful post. I see Holly these days. She has a swollen jaw, but she keeps being the super active and happy cat she has always been, she keeps eating even if she is having some trouble moving her tongue around, she jumps on the bed to sleep with me. To me, she is telling me "give me a shot to continue my life". And that's what we are going to do.

if the surgery does not go well, as you say she will go to heaven while sleeping comfortably under anesthesia. If the surgery goes well, we will all be here to support her, take care of her during the recovery, hoping that she will have a wonderful life for many years ahead. And if the recovery does not go well, I will feel that I helped her get a shot to life and I fought with her until the end.

 

[fionasmom]

I would do the same thing as you have decided. It seems that Holly does have a chance, and given that her quality of life is good, you are not taking that chance away from her by deciding not to proceed.

A lot of people have read this thread and are pulling for you and Holly. Please keep us up to date, as much as you can, as to how things go on Monday. You are definitely fighting the good fight beside her.

 

[botolo]

Update on Holly. Surgery went well! The doctor was able to keep the tongue intact, she completed the mandibulectomy and removed a good margin (hopefully all the cancer is gone). Holly is now under a lot of pain killers in the ICU unit of the hospital and she will stay there for at least another couple of days.

So far so good! Many steps ahead of us...but I am glad she was able to get the surgery done!!!

 

[fionasmom]

Thank you for the update and the good news! I am sure you are a wreck by now and in need of some care yourself. It is great news about the tongue and the ample margins...so hoping that Holly will be able to put this all behind her. Please let us know how things progress. You really did the very best for her and it seems to have paid off.

 

[botolo]

Hello Friends. Holly came back home yesterday. She is still pretty down. Yesterday at the beginning she was acting very active, but she soon started to stay on her own, with her tongue sticking out and drooling. We have been taking a lot of care of her...I am giving pain killer medication three times a day, antibiotics, feeding her four times a day through the e-tube, etc. Today she was feeling a little bit better. I stayed on the bed with her for a few hours and she was purring all the time. She is still far from being OK, but we are taking one step after the other. At this point the important thing is that she does not suffer, so I truly hope that the pain killer medication and the natural healing will progress in the next days.

The mandibulectomy has been radical, so you can see that she does not have almost all lower mouth. A little bit gruesome to look, but she is our baby and we will love her even more than we loved her since now!