Monday, June 28, 2010

Nobody Nose the Trouble I've Seen

A sad day. Another euthanasia. A cat named Lilly. A very interesting case. Lilly was a Maine Coon. Eighteen months ago, Lilly developed signs of an upper respiratory infection. Her breathing became very noisy. She sounded like a bulldog, in fact. Whenever cats have breathing this noisy, it often means that something is present in the nasal cavity. Treatment with antibiotics had minimal effect. In order to figure out what was really going on, we needed to do rhinoscopy. This is a procedure requiring anesthesia. Lilly’s owner agreed to this, so we called Dr. Hopper, the traveling ultrasonographer/endoscopist, and scheduled the appointment.

On rhinoscopy, things looked abnormal. The right nasal passage was swollen, reducing the flow of air through the nose. No masses were seen, though. Biopsy specimens were obtained. Dr. Hopper felt pretty certain that this was a case of lymphosarcoma, a type of cancer. I prepared the owner.
Surprisingly, the biopsy came back as chronic rhinitis – inflammation of the nasal cavity. No cause was determined. This was very frustrating, because “chronic rhinitis” is a pretty vague diagnosis. I mean, duh, it’s pretty obvious that there is rhinitis going on. We needed to know why.

About a week later, we re-examined Lilly, and upon looking in her mouth, I noticed a small growth on the roof of her mouth. This was definitely not there before. We had gotten a pretty good look at the roof of her mouth during her rhinoscopy, when we had to intubate her. Whatever was in her nasal cavity that was not detected during the rhinoscopy was starting to break though the roof of Lilly’s mouth.

I recommended that we snag a biopsy of the mass that was starting to protrude into Lilly’s mouth, but understandably, cost was becoming a concern. These diagnostic procedures are not cheap. With all that money spent on anesthesia and rhinoscopy, was there some other option?

I felt very certain that this mass was lymphosarcoma. Nasal lymphosarcoma is a very common cancer in cats. I suggested that we go with our best guess: the mass is lymphosarcoma, and that we begin the chemotherapy treatment. Nasal lymphosarcoma is very chemotherapy-responsive, and if we’re right, we should see a response fairly quickly. Lilly’s owner agreed.

We began Lilly’s chemotherapy. The chemo protocol we decided to use was a standard protocol that involved weekly intravenous injections for the first four weeks, and various oral medications. The intravenous injections had to be administered very precisely. The drug we were using, vincristine, is a fairly mild, but very effective drug. Cats tolerate it very well, but if you don’t place the intravenous catheter perfectly and some of the drug leaks out into the surrounding tissue, cats will develop a horrible, terrible, disastrous skin reaction. Thankfully, we didn’t have to worry about this with Lilly, because she was the absolute best cat ever, when it came to her chemotherapy. She sat there quietly on the table, giving us her front leg almost willingly, and never flinching or protesting as my technician placed the catheter. We never had to poke Lilly a second time; she was so well-behaved that her cathethers went in smoothly and easily every time. Lilly’s owner leans toward the spiritual/organic/zen side, so she was pleased to hear that vincristine comes from the periwinkle plant. “Tincture of periwinkle” was what we cheekily called it from that point on.

One week later, Lilly was back for her second treatment. Lilly’s owner reported a dramatic improvement in clinical signs. No more bulldog-breathing. I opened Lilly’s mouth. The mass was gone! After just one treatment! I do not like to use a response to therapy as a way to make or confirm a diagnosis, but that was the path we had chosen, and we were right. Lilly’s response was dramatic.
And so it went. After four weeks, Lilly was in complete remission. She was to come back every three weeks for maintenance chemotherapy. The chemotherapy made her lose a lot of her hair (not something that happens often), but other than that, she did great. Her weight fluctuated a bit, and her appetite waxed and waned, but every time I looked at the roof of her mouth, it was normal. Lilly motored along on her chemo. Month after month after month.

One month ago, Lilly came in for another round of maintenance chemotherapy. This time, however, her physical exam was not normal. A lump was evident on the right side of her neck. A nearby lymph node was also enlarged. The cancer was back. A biopsy of the lump confirmed our suspicions: high grade lymphosarcoma.

Although Lilly was out of remission, she was doing pretty well. The mass on the roof of her mouth had not returned, and her breathing was normal. Her appetite was okay, and he weight was fairly stable. After some discussion, it was decided to try to induce another remission using a different chemotherapy protocol. The protocol I chose included the drug doxorubicin, a very effective (but pretty nasty) chemo drug.

Once again, Lilly took her chemo like a champ, never complaining, never resisting. The following week, the node in her neck was unchanged. The week after that, the node was larger. The week after that: still larger. These cancer cells were not like the first population of cancer cells. These ones were resistant. Lilly was losing weight, and her appetite had dropped.

I consulted with an oncologist colleague of mine. Radiation therapy was one option, he said. Lymphosarcoma is a very radiation-sensitive cancer, and this might shrink that lymph node. This, though, was cost-prohibitive. Another chemo protocol was suggested, but the drugs in this protocol were super-expensive. A third chemo protocol, using a drug called CCNU was discussed, and this seemed the best. The drug is a capsule, given orally every few weeks, and the oncologist had reasonable success with it. I was ready to give it a try, especially for a sweetheart like Lilly. We were set to start her new chemotherapy protocol in a week.

Lilly, however, was doing poorly at home. The cancer was taking its toll. She was losing muscle mass. Her appetite was gone. All of the spirit and joy that had possessed Lilly for years was gone. After battling cancer for 18 months, it was time to stop.

And so, this afternoon, I saw Lilly for the last time. We took her out of her carrier. In just a few days, she had lost even more weight, and was weak and scrawny. I’m used to seeing Maine Coons as giant, fluffy teddy bears. Lilly was just a shell of her former self now. She looked defeated. She was ready. Once again, she took her injection, her final one, with no complaints, no resistance, no struggle. Both of her owners were right there with her, and she passed away peacefully and quietly. You get pretty attached to a cat that you see at least once-a-month, and my staff and I became very fond of Lilly, admiring her low-key strength and bravery.

Cat Man Do
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