2015 Pearls of Wisdom

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American Association of Feline Practitioners Conference
October 1-4, 2015 – San Diego, California
Diagnostic Imaging and Oncology 

Pre-Conference Day – October 1

Chronic Kidney Disease: Making the Most of Early Diagnosis, Dr. S. Dru Forrester & Dr. Jane Robertson

  1. SDMA is a new kidney function test that helps identify CKD earlier than traditional tests.
    A new serum renal biomarker, SDMA, allows for identification of CKD on average 17 months earlier than creatinine in cats and is unaffected by lean body mass. Early diagnosis of CKD will provide the opportunity for investigation of an underlying cause and IRIS substaging of the CKD. Earlier management and closer monitoring of CKD will allow for diets and medications to be implemented at the earliest appropriate time to improve quality of life and slow the progression of the kidney disease.
  2. Feeding a renal diet is the only treatment shown to improve quality and quantity of life in cats with CKD.
    Compared with typical feline foods, therapeutic renal foods contain a package of nutrient differences that contribute to their beneficial effects: these include controlled amounts of phosphorus, sodium, and high-quality/highly digestible protein, increased amounts of potassium, omega-3 fatty acids, and antioxidants, and alkalinizing ingredients.  Today’s commercially available renal foods are highly palatable and > 90% of cats with CKD can be effectively transitioned to eating a renal diet. For fussy eaters, some additional tips can ensure a successful transition (Education – of cat parents about importance of nutrition; Ambience – avoid offering renal foods in the hospital or when the cat is feeling ill or stressed; Transition –  some cats need time (several weeks) to adapt to a dietary change). 

End of Life Issues in Feline Medicine, Dr. William Folger

  1. Ethical and moral considerations, fundamental to what constitutes being a veterinarian, are inherent in end of life considerations in feline medicine. The deployment of our aesculapian authority all of us inherit as the direct result of our education, training, and experience defines who we are and what we believe.
  2. The misuse of this authority can lead to moral stress and ultimately to compassion fatigue. Every veterinarian is interested in advocating for the patient first in order to prevent unnecessary pain and suffering. Quality of life scales have been described for use in feline medicine to help decide what is in the best interests of our feline patients.

Death &Dying: Feline Euthanasia in the Clinical Setting, Dr.  Elizabeth Colleran 

  1. Given clients’ expectations and the impact of end-of-life conversations on pet owner and the veterinary team, compassionate communication should be considered both a core clinical skill and an ethical obligation for veterinarians.
  2. It is critical that all technical matters and procedural decisions be made with the central focus of reducing or eliminating any form of fear, pain, or distress the cat might experience. 
  3. Without the use of topical anesthetic and biocclusive dressings which take 20 to 30 minutes to be effective, catheter placement is at best uncomfortable and maybe painful. 

Controversies Surrounding Protein in Feline Nutrition, Dr. Margie Scherk

  1. In nature, cats eat multiple small meals/day. This is reflected in their shorter intestinal length:body size than other species. The small size of their prey has shaped their social structure and need to protect their territory (food resources). Eating multiple small meals results in less urine pH fluctuation as well as greater water intact than eating one or two large meals/day does. Additionally, the nutritional composition of their prey has influenced their dentition as well as their digestive processes.
  2. Surgically gonadectomy reduces cats’ metabolic energy requirements by 20-25%. Reducing caloric intake accordingly, is a simple and practical way to help prevent obesity.
  3. In the native diet of cats, ~ 50% of calories come from protein (as fed), 40-46% from fat and <10% from nitrogen free sources (carbohydrate). As a consequence, cats are capable of avoiding ketonemia from very high levels of protein. They are capable of utilizing carbohydrates for energy, however there appears to be a benefit to feeding a higher protein, lower carbohydrate diet for diabetes and for weight loss.
  4. Sarcopenia is associated with increased morbidity and mortality in cats. Whenever a therapeutic diet is recommended, a recheck should be performed to assess how well the diet suits the individual patient. Muscle condition score (MCS) reflects protein adequacy whereas body condition score reflects caloric adequacy. MCS should be evaluated in every cat.

Emerging infectious Diseases, Dr. Susan Little

  1. Awareness of emerging infectious diseases is important so that clinicians do not misdiagnose patients that may represent new cases of previously rare or unknown diseases in the practice area.
  2. While vector-borne pathogens have not been as well studied in cats compared to dogs, clinicians should be aware that pathogens such as Anaplasma may be an important and often overlooked cause of clinical disease in cats.

Day 1 – October 2

Feline Pain Management Guidelines, Dr. Michael Petty and Dr. Ilona Rodan

  1. In most cats, pain, especially chronic, does not exhibit itself by physical manifestations. Instead, most cats demonstrate pain through behavioral changes.
  2. As in other species, NSAIDs are the mainstay for the treatment of chronic pain in cats. Although renal toxicity is a consideration, cats on long-term meloxicam did not have a reduction in lifespan, and long-term low dose use in cats with stable chronic kidney disease provides effective analgesia without progression of kidney disease. Follow-up examination, diagnostic testing, and client education are necessary.  

Thoracic Ultrasound: Feline Thoracic Disease, Dr. Livia Benigni

  1. Ultrasound may be used as the first imaging technique in the dyspneic cat. The examination can be done standing and is excellent for detection of pleural effusion, mediastinal neoplasia, and cardiac disease.
  2. Thoracic lesions are not visible on ultrasound if aerated lung is in between the probe and the lesion. If a pulmonary lesion is in contact with the thoracic wall, ultrasound can be used to guide the biopsy needle.

Feline Thoracic Radiographs: Interpretive Principles & Normal Variations, Dr. Lorrie Gaschen

  1. Both ventrodorsal and dorsoventral thoracic radiographs should be used in obese cats when there is a suspicion of pleural fluid. If the heart contour definition changes between the two, being worse on the DV, then pleural fluid is present.
  2. Older, thin cats can be falsely diagnosed with bronchial disease due to the hyperlucency of the thorax and increased conspicuity of their bronchial tree.

Ultrasound of Feline Gastrointestinal, Hepatic, &Pancreatic Diseases, Dr. Livia Benigni

  1. Ultrasound is more reliable than radiology to detect intestinal foreign bodies. With regards to the intestinal wall, ultrasound offers better resolution than CT. Subtle signs suggesting intestinal disease (e.g. thickening of the muscularis layer, focal loss of wall layering) may be detected with ultrasound.
  2. In case of feline triaditis: ultrasound is not an accurate method to detect abnormalities and cannot reliably predict from which organ to take biopsies.

Improve Your Radiographic Interpretation of Feline Abdomen, Dr. Lorrie Gaschen

  1. An irregular and heterogenous soft tissue opacity causing lack of abdominal serosal detail in cats is likely due to peritonitis or carcinomatosis.
  2. The empty or mildly fluid-filled stomach silhouettes with the liver and can lead the viewer to believe that the cat has hepatomegaly. In these instances either barium should be administered to identify the stomach separately from the liver or ultrasonography should be performed. 

Lunch & Learn –Updates in Pain Management, Dr. Michael Petty

  1. Treating pain is not just about drugs.  It is important to consider some of the complimentary modalities, such as physical rehabilitation and acupuncture, which have received recent support and evidence for their use.
  2. You cannot treat what you don’t understand.  It is important to utilize many of the new pain scales to not only understand when your patients are in pain, but to monitor their response to treatment as well.

Imaging: Feline Urinary Tract Disease, Dr. Livia Benigni

  1. Ultrasound is an excellent technique to assess the kidneys and detect ureteral obstruction. Ultrasound guided injection of contrast into the renal pelvis (antegrade pyelogram) may be necessary to confirm the presence of ureteral obstruction.
  2. Ultrasound is unreliable in case of urinary tract rupture; contrast radiography is the modality of choice. Negative contrast medium (air) should not be used in case of suspected trauma/ urinary tract rupture. 

Obstructed or Not? Get the Most from Abdominal Radiographs, Dr. Lorrie Gaschen

  1. A three view radiographic procedure is required in every vomiting cat; a right and left lateral and a VD image. Left lateral places gas in the pylorus and duodenum to find foreign material better.
  2. Wooden spoon compression should be used routinely to separate loops of jejunum from one another so that foreign material, linear foreign bodies and corrugations can be detected without superimposition.
  3. Barium studies and ultrasound should only be performed after compression radiography results in a negative finding.

Dental Radiography Updates, Dr. Brook Niemiec

  1. The near parallel technique is easier to maser and more consistent than the extraoral technique for removing the zygomatic arch from maxillary premolar images.
  2. Almost all radiographs can be obtained with 3 angles 20, 45, and 90.

Improve your Interpretation of Radiographic Pulmonary Patterns in the Cat, Dr. Lorrie Gaschen

  1. The presence of a large lung volume together with a homogenously soft tissue opaque right middle lobe is due to lower airway disease and right middle lobe atelectasis. This should not be mistaken for aspiration pneumonia.
  2. Pulmonary fibrosis has many radiographic appearances which can mimic asthma, pneumonia and neoplasia. Computed tomography is helpful for differentiating these.

Feline Bones: Musculoskeletal Review, Dr. Zoe Lenard

  1. Don’t compromise on technique: in order to get the best information from your radiographic study consider appropriate sedation or anesthesia and attempt to optimize image quality for small bony structures. Radiograph the contralateral limb frequently for comparison.
  2. Primary bone tumors in cats are rarer than dogs with osteosarcoma and squamous cell carcinoma common. Diseases causing gene mutations (mucopolysaccaridosis and osteochondrodysplasia) are also rare but may mimic aggressive bone lesions like neoplasia: consider obtaining survey skeletal radiographs in cats with unusual changes in peripheral limbs.

Radiographic Interpretation of Heart Disease in Cats, Dr. Lorrie Gaschen

  1. Cardiomegaly in cats with hypertrophic cardiomyopathy is primarily due to enlargement of the left atrium and has been falsely described as biatrial enlargement due to the valentine shape of the heart on the VD image.
  2. A vertebral heart score of >7.9 has good accuracy for differentiating cats with left sided heart disease from healthy cats.

Do Cats Have 9? Imaging in Cases of Feline Trauma, Dr. Zoe Lenard

  1. In cases of pelvic trauma, obtain two ventrodorsal projections: the frog-legged or neutral projection to assess the pelvic bones and the VD-extended projection to assess the femoral head and neck as subtle fractures may be missed without this view.
  2. Thoracic radiography is essential in the assessment of the dyspneic cat, but these patients are fragile! Stabilize first with oxygen and sedation (if appropriate), consider a DV projection to minimize stress and a limited thoracic ultrasound to check for pleural fluid, treat appropriately then obtain a full radiographic series once stable. 

Special Sonographic Features of the Feline Abdomen, Dr. Lorrie Gaschen

  1. Hepatic lipidosis and lymphoma cannot be distinguished sonographically as they can both lead to diffuse hyperechogenicity and hepatomegaly. Cytologically, both can have lipidosis present and the underlying cause of liver disease can be missed unless histology is performed.
  2. A “gunshot” appearance of the liver on ultrasound examination is usually due to biliary dilation. Biliary cystadenomas and cystadenocarcinoma can appear similarly and require tissue sampling to differentiate

Day 2 – October 3

Feline Dental Radiology Masterclass & Hands-on Lab, Dr. Brook Niemiec

  1. Dental radiographs are critical for determining treatment options for tooth resorption in cats.
  2. Full mouth radiographs in most cats will be 10 images and should be performed on all cases.

Imaging of Round Cell Neoplasia in the Cat, Dr. Zoe Lenard

  1. Lymphoma shows diversity in its morphology and behavior in the cat, despite being one of the most common neoplasms affecting this species. Imaging is required to assist with accurate staging of the disease and ultrasound using a high frequency transducer will allow staging of many forms of the disease.
  2. Understanding the typical imaging appearance of high grade and low grade alimentary lymphoma will help clinicians to select the best sampling method (needle aspirates or biopsy). No imaging features of lymphoma are pathognomonic; clinicians need to consider other differentials (neoplastic and non-neoplastic) that may appear similar to the imaging features of lymphoma.

MRI & CT for Feline Practitioners, Dr. Livia Benigni

  1. MRI is preferred to CT for visualization of soft tissue detail and is the modality of choice for brain and spinal diseases. CT is superior to MRI in case of skeletal fractures and pulmonary disease.
  2. Abdominal CT is of limited value without the use of contrast, ultrasound is an excellent alternative to abdominal CT in case of feline abdominal disease.

Understanding the Cat & Feline-Friendly Handling Part 1 and 2, Dr. Ilona Rodan

  1. Understanding the underlying causes of fear surrounding the veterinary visit – the carrier, the owner’s unusual behavior, the car, the hospital environment, and the handling – can help us eliminate or at least reduce the feline patient’s fear.
  2. Cats demonstrate 3 major fear responses.  When we recognize these, we can differentiate our handling techniques based on these responses, facilitating examination and lab sample collection, and preventing escalation of fear and human injury.

CT of the Feline Head, Dr. Zoe Lenard

  1. Complex radiographic anatomy makes CT a far superior test, and CT should be considered as the first line imaging modality in cases of trauma, nasal disease, facial distortion, middle ear disease, or suspected neoplastic disease.
  2. CT is the best way to evaluate the temporomandibular joints for fractures (particularly those that are non-displaced) as these lesions cannot be detected radiographically and may severely impact jaw function in the cat.

Choosing & Using Radiology & Ultrasound Equipment, Dr. Livia Benigni

  1. Avoid buying products that are towards the end of their technical life, as they would not be supported. Avoid getting products from undercapitalized companies or from companies with a different primary focus as you may end up unsupported.
  2. When choosing the equipment to buy, take into consideration whether your clinic offers feline only or feline and canine medical care.

Managing the Feline Cancer Patient Part  1 and 2, Dr. Erika Krick

  1. Obese cats can be cachectic!  Current body condition scoring methods assess fat deposits, not muscle mass.  A cat that has significant muscle loss would still be considered cachectic even if the body condition score is high.  It is essential to assess muscle mass as well as body condition score in cats with cancer.
  2. Honest and compassionate client communication is essential for maintaining a high quality of medical care to the patient.  Specifically, conversations about goals of treatment, ease (or not) of medicating and transporting the cat for treatments, and how the client feels the cat is doing will aid in developing appropriate care plans that are agreeable and feasible for the cat and the client.
  3. Compounding pharmacies may become your closest friend.  They offer a variety of oral and transdermal medication formulations that may make it easier for your client to follow your medication instructions.  It is important to find out from clients how well they are able to medicate their cat so that you can discuss any problems and potential solutions together.
  4. Gastrointestinal toxicity is more likely to impact a cat’s quality of life than neutropenia.  Because of this difference we are more likely to reduce the dose of a drug if a cat is experiencing gastrointestinal toxicity versus bone marrow toxicity. It is important to get accurate information from the client about any chemotherapy side effects and monitor the cat’s weight as an assessment of treatment tolerance. 

Kitties in Crisis: Emergency Care for Cats, Ms. Erica Mattox

  1. Cats are very subtle in their manifestations of critical illness and disease.  These subtle clinical signs may only be a small glimpse regarding the severity of the condition.  Initial assessment of a cat should happen quickly and as stress free as possible.
  2. The best technicians for critical care are the ones who are proactive and have forward thinking skills. They have the ability to diligently monitor their patient and observe subtle changes. Sometimes an emergency is obvious but sometimes it is not. Picking up on a new respiratory pattern or the slight agitation that the patient was not previously displaying will help you to detect an emergency in a timely manner.  The ability to assess accurately and rapidly marks the difference between a good veterinary technician and an excellent one. 

How to Survive the Hospitalized Cat: Feline Patient Care, Ms. Erica Mattox

  1. Stabilization and treatment for kitty crisis often requires hospitalized care for extend period of time.  Care of hospitalized feline patients should promote wellness or recovery from illness or injury and addresses the patient’s physical and emotional wellbeing.  Kitty patient care should help the recovering patient engage in normal cat behaviors and activities that it is unable to perform on its own such as grooming.
  2. When interaction is welcomed provide non-medical interaction.  Not all time spent in feline patient care should involve an unpleasant treatment based interaction with the kitty. It is important that patients receive care that promotes their environment and ultimate experience.  These interactions should include; TLC (grooming, walking, petting), quiet time to rest, and interaction.

Lunch and Learn- Update on Feline Anaplasmosis, Dr. Michael Lappin

  1. Cats exposed to Ixodes spp. ticks can develop fever and mild thrombocytopenia from Anaplasma phagocytophilum infection.  The range of the infection is similar to that for Borrelia burgdorferi infection in dogs.  Thus, if you see cats with appropriate clinical or laboratory findings in the regions recognized as endemic for Lyme disease in dogs, the cat could have anaplasmosis.
  2. The combination of serology and PCR assays can aid in making the diagnosis of feline anaplasmosis.  Doxycycline is an effective treatment for clinical signs of disease.  Tick control should help lessen risk of infection.

Oral Tumors in Cats: Hope for the Future, Dr. Annette Smith

  1. Feline oral squamous cell carcinoma remains a challenging disease to treat, with a generally poor prognosis. Surgery can be useful for selected cases, usually with mandibular and rostral, small tumors, with long-term survivals.
  2. Palladia has shown some treatment responses in cats with oral squamous cell carcinoma, and appears to be well-tolerated. With the identification of further potential targets, in conjunction with the development of targeted therapy, better treatment options for this disease may be on the horizon.

Feline Lymphoma, Dr. Erika Krick

  1. Body weight can be used as a surrogate marker for treatment response and tolerance.  If a cat is consistently losing weight during chemotherapy treatment, it is reasonable to recommend restaging or consider modifying the protocol to improve tolerance.
  2. There is no one completely reliable test to distinguish between small cell lymphoma and inflammatory bowel disease.  The clinician must weigh all clinical factors and diagnostic results when deciding how to move forward with treatment.  

Kitties vs. Kidneys: Feline Kidney Disease, Ms. Erica Mattox

  1. The kidneys are the functional organs of the urinary system.  They kidneys are uniquely susceptible to injury due to the large quantity of blood filtered for each cardiac cycle, regional differences in blood supply within the kidney, and a high rate of metabolic activity of renal tubular cells. 
  2. Renal disease is one of the most common diseases that affect feline patients.  Depending on the disease or injury, the kidney injury may be acute or chronic.  Both are identified by an elevation in serum creatinine and blood urea nitrogen known as azotemia.  When the kidneys are injured they cannot filter properly which leads to abnormal fluid levels in the body, deranged acid/base levels, hematuria, anemia, isosthenuria, and abnormal levels of potassium, calcium and phosphate.

Management of Feline Large-cell Lymphoma Updates, Dr. Annette Smith

  1. Overall, 1/3 of cats with large-cell lymphoma do not respond to our typical CHOP protocol, and the remaining 2/3 have variable responses, with a median survival time of around 10 months for complete responders. Rescue with CCNU for non-responders or relapsed patients may provide additional survival time.
  2. Approximately 1/3 of cats with excellent responses may benefit from shorter protocols with no maintenance to minimize treatment side effects while still providing a 2-3 year prognosis. A prospective, controlled study is needed to prove this theory, and identification of pre-treatment diagnostics would be useful to better define which patients would benefit from this regimen.

Neoplastic Effusions, Dr. Erika Krick

  1. Currently lymphoma is the only treatable cause of neoplastic effusion in cats.  Supportive or palliative care only is available for other neoplastic effusions.
  2. Don’t be fooled by reactive mesothelial cells!  These cells can look very dysplastic if there is an effusion from any cause, including neoplastic and non-neoplastic diseases.

Trouble in the Urethra: Feline Lower Urinary Tract Disease, Ms. Erica Mattox

  1. Owners play a critical role in the treatment of FLUTD.  Helping owners practice appropriate husbandry such as having the correct number of litter boxes, scooping them daily, making sure they are in more than one location and away from loud machines, etc.  Also, making sure there is more than one water source in the house is recommended.  In those cats that like running water sources, obtaining and using a water fountain type machine for them is recommended to encourage greater water intake. 
  2. Inflammation due to FLUTD, regardless of the cause results in pain upon distention of the bladder or urethra.  This pain causes the patient to empty their bladder more often, resulting in smaller volumes of urine being voided.  Blood may be present as the fragile epithelial lining is stretched or from trauma caused by crystals or stones.  The bladder will be small or even empty upon examination of the patient.  Should there be sufficient protein and or debris to cause intraluminal urethral obstruction, the patient will strain ineffectually producing minimal to no urine but present with a large, full bladder.

Day 3 – October 4

Secrets to Improve Quality-of-life for Cats with Cancer, Dr. Greg Oglivie

  1. Compassionate care is the single most important thing in all of veterinary medicine. It is composed of two things: meeting the medical needs of the patient and the non-medical needs of the client.
    • The first step is to provide compassionate care by dispelling the myths and misperceptions about cancer and cancer care. Cancer is a disease that defines the lack of hope. Our job is to replace the misperception with facts while providing honest, realistic, truthful hope. 
    • The second is to create a team that supports your mission of providing extraordinary feline-centric compassionate care. The best care comes from a unified approach that begins with client support services, is extended and magnified through the nursing and animal care teams, and is topped off by the rest of the veterinary health care team.
    • The third step is to provide unparalleled feline specific care from the science as well as the heart. Cancer is not only the most curable of all chronic diseases, but it is the target of the most remarkable advances in veterinary medicine.
  2. Understand that many of our clients (and the entire feline health care team) have three fears that, if not addressed will be hidden concerns. They are afraid that cancer and cancer care will cause pain, gastrointestinal problems and loss of appetite. Turning these fears into topics of discussion is the right thing to do for the client and the patient.
    • The first commandment is don’t let them hurt. Preventing discomfort and responding proactively to minimize pain must be our first and greatest effort.  Diminishing discomfort with NSAIDS, Acupuncture, local blocks, opiates and other analgesics is important. 
    • The second commandment is like unto the first, don’t let them vomit or have diarrhea. Ondansetron, maropitant and metoclopramide can be quite helpful for cats. 
    • The third commandment is paramount. Don’t let them starve. Indeed, appetite is equated with quality of life.  Mirtazapine at appropriate dosages in kitties without renal or hepatic disease can be effective. 

Chemotherapy Drugs, Dr. Erika Krick

  1. Cats seem to tolerate receptor tyrosine kinase inhibitor drugs well.  Small reports of using these drugs for mast cell tumors and injection site sarcomas are promising.
  2. In addition to assessing white blood cell counts, it is important to evaluate renal function in cats prior to some chemotherapy drugs.  Doxorubicin can be nephrotoxic and the toxicity of carboplatin is increased in patients with renal dysfunction. 

Care Beyond a Cure: Diagnostic Secrets & the Cancer Patient, Dr. Greg Oglivie

  1. The only time a diagnostic test should be run is if it will change the client’s willingness to treat or the way we would treat the kitty.  Regardless, we cannot defeat what we do not know. Thus, the three golden rules of oncology are: 1. Biopsy! 2. Biopsy! 3. Biopsy! The diagnostic quality of the biopsy is related to the way it is obtained, the location that the sample is acquired, and the skill of interpretation. When a biopsy is planned, one key question should be considered. How will the biopsy influence the definitive therapy? This is most evident when considering a biopsy of a mass on the face. If a long incision is made to biopsy a mass in an area with limited skin, the definitive surgery would have to not only remove the incision, but also the mass itself. Thus, think of the whole approach.
  2. Molecular diagnostics are the way of the future, however some of these diagnostics are in their infancy in feline medicine and surgery. PPAR is superior to flow cytometry for the diagnosis of lymphoma in the cat. This has been used to confirm that most GI lymphoma cases are T cell in origin, especially if it arises from the small intestine. Cats with lymphoma of the stomach and colon tend to have B cell lymphomas. Those with lymphoma primarily of the mucosa tend to be small cell and their survival is quite long, whereas those that are transmural are often large or intermediate in size and are often associated with more limited remission times. 

Less Common Cat Cancers, Dr. Erika Krick

  1. Cats with splenic mast cell tumors can have a good prognosis after splenectomy, even if they have circulating mast cells. There is no evidence to suggest that adjuvant chemotherapy is necessary after surgery for those cats.
  2. If you are working up a patient for multiple myeloma, evaluate the liver and spleen via ultrasound and/or cytology in addition to the other tests.  Involvement of the liver and spleen is frequent enough in multiple myeloma that it is reasonable to consider it as part of the diagnostic criteria in cats.  

Injection Site Associated & Other Soft Tissue Sarcomas: New Advances for 2015, Dr. Greg Oglivie 

  1. Soft tissue sarcomas are made up of a family of different tumors, but they all behave the same: They are highly locally invasive with a relatively low probability of metastases. The metastatic rate is dependent on the grade of the tumor. Feline soft tissue sarcomas are highly aggressive with a very high probability of recurrence. The difficulty in controlling this tumor is compounded by the presence of skip metastases that must be considered when developing the treatment plan. 
  2. CT scans are very important to determine the extent of the disease which enhances cure rates and in the grand scheme of things, keeps the overall cost of care down. It is odd that spending money can save money, but that is true in this disease. This diagnostic test often doubles the amount of disease that is perceived compared to physical examination alone. 
  3. Surgery, especially those that achieve 5 cm margins has been shown to be effective for local control of soft tissue sarcomas. Radiation therapy is clearly the most important treatment after surgery to delay or prevent recurrence.  Doxorubicin based chemotherapy and/or feline interferon delivered by a canary pox vaccine has been confirmed in the published literature as effective adjuvant treatments. Metronomic therapy has been shown in a number of species with soft tissue sarcomas to delay or prevent recurrence or tumor progression. 

Top Oncology Mistakes & How to Avoid Them: Part 1 and 2, Dr. Sue Ettinger

  1. Don’t monitor the bump or lump. Do get an aspirate or biopsy. See something do something. Why wait? Aspirate.
  2. Don’t remove a mass without knowing what it is.
  3. Cancer is not a death sentence.
  4. Don’t assume clean surgical margins were clean.
  5. Don’t treat cats like small dogs when giving chemotherapy.
  6. Don’t assume your client would never treat the cat for cancer. 

10 Best Kept Secrets For Treating Cats with Cancer, Dr. Greg Oglivie 

  1. Secret #1: Cats generally resist restraint; and therefore, the less restraint is generally the best restraint. Cats are not small dogs.  Despite how feline medicine is presented in most veterinary schools and conferences, the diseases are unique, as is the therapy. Cats are made of steel.  Indeed, unlike what many veterinarians are taught, cats generally do extraordinarily well in adversity and generally do well with cancer therapy.  When comparing dogs and cats who are treated with chemotherapy and radiation therapy, cats generally do far better than dogs.  Evil cats live forever.  This is subjectively true, as the meanest cats tend to be those that are more aggressive, and therefore more willing to fight to stay alive, regardless of the threat in front of them. Clients are not truthful if they say they give all the medications.  Indeed, the fewer medications the client is to give, the more likely they are to administer it. Therefore, prescribing medications with the least number of administrations per day will result in the highest compliance rate.  Studies have shown that only 30% of all the medications given to cats are given as prescribed.  Most cats with cancer are anemic.  Indeed, anemia of chronic disease is a powerful influence on the hemogram.  Since cats disassociate oxygen from the hemoglobin of red blood cells far easier, and the oxygen disassociation hemoglobin curve is far different in the cat than the dog, this is not as high of an issue.  
  2. Secret #2: Cats with metastasis rarely cough until the end-stage of the disease, whereas cats with reactive airway disease frequently cough very early on in the course of the disease. Size of the feline mammary tumors and the extent of the complete surgical mastectomy are prognostic.  
  3. Secret #3: A dyspneic cat is a cat with severe intrathoracic or upper airway pathology. Chest radiographs are often the best tool for diagnosing respiratory abnormalities.  However, because cats present late in the course of their disease, extreme caution should be taken when taking chest radiographs in the cat. A cat with severe dyspnea plus normal chest radiographs almost always is associated with a functional airway disease, such as asthma, thromboemboli, etc.  Feline asthma is frequently associated with radiographic “doughnuts.” Collapse of the right middle lung lobe is a common sequela to chronic lung disease and often results in the inability to obtain a normal-looking chest radiograph on a VD because the heart shifts towards the side of the collapsed lung lobe.  
  4. Secret #4: As with the dog, the three commandments of cancer care are extraordinarily important.  The first commandment is “Don’t let them hurt,” the second commandment is “Don’t let them vomit or have diarrhea,” and the third commandment is “Don’t let them starve.” The first commandment, “Don’t let them hurt,” is of extreme importance; in one study, published in the Journal of the American Veterinary Medical Association in 2005, a survey of clients revealed that at least 50% of cats with cancer are in pain.  So, even if we don’t think that cats are medically in pain, we should take into account the clients’ perception of what is going on. Therefore, prevention of discomfort is of extreme value; considering preemptive analgesics, non-steroidals, opiates, tramadol, acupuncture, and local blocks can be of great value.  
  5. Secret #5: Piroxicam, Metacam, Onsior, ketoprofen and, even in some countries, carprofen, have been shown to be of great value at alleviating pain and suffering.  The chronic use of oral meloxicam in the United States is now no longer possible because of the black labeling by the Food and Drug Administration. This is really unfortunate because this drug is easy to administer, very tolerable, and has great efficacy. Piroxicam itself has been shown to have an anti-cancer effect in the cat, including transitional cell carcinoma, mammary carcinoma, intestinal carcinoma, and squamous cell carcinoma.
  6. Secret #6: Tramadol is effective for treating pain in the cat when combined with other drugs despite its bitter taste and, therefore, poor palatability. Indeed, this particular drug must be compounded and hopefully can be created by a compounding pharmacist in a palatable liquid or in a capsule to hide its bitter taste. Adverse effects are rare in the cat; however, respiratory depression has been reported.  
  7. Secret #7: Oxymorphone and fentanyl are two of the most commonly used opiates in the cat other than buprenorphine and butorphanol.  Fentanyl patches are effective at providing continuous analgesia in the cat. It has an efficacy of analgesia for three to five days.  When fentanyl is administered intravenously, it is rapidly absorbed and has at least and hour and a half of analgesia.  Hydromorphone has an advantage over morphine in the fact that it does not cause histamine release and the hyperexcitability, gastrointestinal and respiratory problems associated with morphine administration. Other opiates that are commonly used in veterinary practice include butorphanol, which has analgesia of one half to two hours, but a sedation that lasts for four hours; morphine, which has sedation, as well as analgesia, and lasts for six hours; and buprenorphine, which has a duration of analgesia that lasts for 8 hours.
  8. Secret #8: If a splenic mast cell tumor is identified, then the prognosis can actually be quite good.  Survival times with splenectomy have been reported to exceed two years.  
  9. Secret #9: Radiation therapy with a radiation sensitizer, such as gemcitabine, has been touted as being highly effective; but ultimately, when comparing oral facial squamous cell carcinomas, bone involvement is generally a good prognosis. Unlike in the “other species,” surgery alone is often associated with long-term control and/or cure.     
  10. Secret #10: A jaundiced cat is not necessarily a dead cat. In fact, jaundiced cats can live for a long period of time with limited impact to the quality of life. Liver enzymes are not elevated in 25% of cats with significant liver disease. A liver biopsy is absolutely essential to be able to identify the liver disease.
  11. Secret 10.5: Caring for yourself as a kitty caregiver is vital. This can be done in part by: finding a deeper satisfaction, meaning to work; strengthening your original sense of calling; identifying yourself as healers among healers; discovering you are not alone; learning tools of self-care; and renewing your commitment to yourself, your patients and the profession.

Diarrhea Dilemma: What We Think We Know About Treatment of IBD, Dr. Susan Little

  1. Diagnosis of IBD remains one of exclusion so a systematic approach is key to maximize diagnostic efficacy and avoid misdiagnosis.
  2. A sequential approach should be applied for therapeutics to individualize treatment to the patient.

Kitty Oncologic Emergencies: HELP!!!, Dr. Greg Oglivie 

  1. Emergencies come in many forms: True emergencies, perceived emergencies and emergencies of convenience. The presence of cancer magnifies the emotion associated with emergencies. Dealing with the fear, myths and misperceptions associated with emergencies and cancer is important. Calming the fears, anxiety of the client can be just as important as calming and caring for the cat in a feline friendly environment. 
  2. A dyspneic cat needs to be dealt with calm efficiency. Do not stress the patient. Oxygen and gentle, quiet care is vital. Radiographs are very helpful. Consider all the differentials before developing a diagnostic and therapeutic plan. Prognosticate responsibly. 
  3. Anemic cats that present for emergency or critical care support must be cared for with gentle, quiet, feline friendly members of the veterinary health care team. Securing blood work after the patient has been allowed to oxygenate, hydrate, and calm. Blood transfusions should be given for support, but every effort should be made to find the underlying cause of the anemia. 

See Something, Do Something. Why wait? Aspirate™, Dr. Sue Ettinger

  1. See Something: If a skin mass is the size of a pea (1 cm) and has been there 1 month,
  2. Do Something: Aspirate or biopsy, and treat appropriately!
  3. Obtaining a definitive diagnosis with cytology or biopsy early and before excision will lead to improved patient outcomes for superficial masses.  When in doubt, send the sample out. A practical recommendation for non-diagnostic cytology and the lesion fits in an 8 mm punch biopsy, then PUNCH IT OUT. If the mass is larger than an 8 mm punch biopsy, an incisional biopsy (wedge, tru-cut, punch) is required for diagnostic confirmation.
  4. Most skin and subcutaneous tumors can be cured if diagnosed early when masses are small.  The first surgery is the best chance for cure for many tumors.  Let’s find them earlier and aspirate them when they are small. Early detection saves lives.

The Secret Weapon: Polyunstaruated Fatty Acids & Cancer: Advances for 2015, Dr. Greg Oglivie

  1. Long chain polyunsaturated fatty acids of the n-3 and n-6 series are essential for health and wellness in the cat. Excessive or insufficient amounts of either can result in sickness and death. In our world, there has been a general trend toward an increase in pro inflammatory n-6 fatty acids, whereas there has been  a decline in the amount of n-3 fatty acids. This results in a gradual increase in the number of inflammatory disorders such as obesity, degenerative joint disease, steatites, cognitive dysfunction and cancer. 
  2. Normalizing polyunsaturated fatty acids of the n-3 series  such as docosahexaenoic acid can reduce pro-inflammatory pathways and can be used therapeutically for a number of disorders in the cat such as atopic or allergic lung and skin disease, cognitive dysfunction (with antioxidants etc), degenerative joint disease, renal disease and cancer. 
  3. Long chain polyunsaturated fatty acids have been shown to have a direct anticancer effect. The mechanism of this action is complex but is associated with the inhibition of matrix metalloproteinases, induction of lipid peroxidation, apoptosis, anti angiogenesis, etc. The end effect is a direct anticancer effect and an ability to augment the efficacy of the immune destruction of cancer along with enhancement of the efficacy of radiation and chemotherapy. 

Practical Take-home Tips for Managing Feline Cancer Patients in Your Practice, Dr. Sue Ettinger

  1. The overall toxicity rate is very low in veterinary chemotherapy patients. Most side effects are mild and medically manageable. In my experience, only 15-20% experience side effects, and this is even less common in cats.  The primary goal is to provide the best quality of life possible for as long as possible. As I say, live longer, live well.  Most side effects are mild and medically manageable.
  2. Don’t forget the exam – especially the temperature – when checking a nadir CBC after chemotherapy. 
  3. Get the blood sample from the jugular vein (unless thrombocytopenic).
  4. Pay attention to the neutrophil count, not the total white blood cell count. The nadir typically occurs 7 days after chemo administration, but can vary with some chemotherapeutics.   I recommend antibiotics if the neutrophil count is <1500. If the cat has <1500 neutrophils and is afebrile and feeling well, I recommend managing as an outpatient. However, if the cat has <1500 neutrophils and is febrile and sick, I recommend admitting for supportive care. Remember a febrile neutropenic is an oncologic emergency.

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