AAFP 2015 Proceedings Book For Web

2015 American Association of
Feline Practitioners
presents
3rd World Feline Veterinary Conference
Diagnostic Imaging and Oncology
Partnering with the

International Society of Feline Medicine
October 1- 4, 2015
Manchester Grand Hyatt
San Diego, California USA
Proceedings Sponsored by
www.catvets.com/education
PROCEEDINGS
2015
3 WORLD FELINE
rd
INDEX
VETERINARY Welcome . . . . . . . . . . . . . . . . . . . . . . . . . 1
CONFERENCE Sponsors . . . . . . . . . . . . . . . . . . . . . . . . . 2
Program Agenda . . . . . . . . . . . . . . . . . . 3
Distinguished Speakers . . . . . . . . . . 11
President’s Welcome Message Session Abstracts . . . . . . . . . . . . . . . . 15
Membership . . . . . . . . . . . . . . . . . . . . . 20
Welcome to San Diego! We are so glad you have joined us for the
Third World Feline Veterinary Conference held in partnership with Thursday
the International Society of Feline Medicine. Our focus this year is Pre-conference Day
on Diagnostic Imaging and Oncology with a world-class panel of Proceedings . . . . . . . . . . . . . . . . . . . . 23
speakers. The learning starts with the Food for Thought Luncheon Friday
(sponsored by Hill’s Pet Nutrition) and the ABVP/AAFP Seminar Combined Track Proceedings . . . . 49
and Social pre-conference sessions on Thursday (sponsored by Bayer Track A Proceedings . . . . . . . . . . . . 57
HealthCare). The pre-conference day will cover a variety of topics such as chronic kidney Track B Proceedings . . . . . . . . . . . . 83
disease, end of life issues, emerging infectious diseases, and feline nutrition. The following Lunch & Learn Proceedings . . . . 109
three days are filled with two professional tracks and one para-professional track of engaging
Saturday
and cutting edge lectures. We are very pleased to present a feline dental radiology wet lab
Combined Track Proceedings. . . 115
this year as well as lunch time learning opportunities.
Track A Proceedings . . . . . . . . . . . 121
Track B Proceedings . . . . . . . . . . . 139
There is no lack of social time in our schedule with the Thursday evening Welcome
Para-professional Track
Reception (sponsored by Boehringer Ingelheim), the Happy Hour reception in the Exhibit
Proceedings . . . . . . . . . . . . . . . . . . . 157
Hall on Friday evening (sponsored by Bayer HeatlhCare), and the Polynesian Paradise
Lunch & Learn Proceedings . . . . 181
event on Saturday evening at the Bali Hai Restaurant on Shelter Island (sponsored by
Dental Lab Proceedings . . . . . . . . 183
Elanco). Don’t forget to get some exercise with the 8th annual AAFP Fun Run/Walk on
Saturday morning. Sunday
Track A Proceedings . . . . . . . . . . . 193
Coming partway through our year, this conference gives us a moment to reflect on what Track B Proceedings . . . . . . . . . . . 261
we’ve accomplished so far. It has been an excellent year for feline continuing education Lunch & Learn Proceedings . . . . 285
with presentations at the American Veterinary Medical Association meeting in Boston in
July and AAFP tracks at the NAVC, AAHA Conference, and all three CVCs. The NAVC
American Association of
Institute course on feline medicine – Finessing the Feline – was held in July and for the Feline Practitioners
first time, AAFP members received a discounted registration. A full listing of education 390 Amwell Road, Suite 402
events supported by AAFP is on our website. You can also access excellent feline continuing Hillsborough, NJ 08844
education without leaving home via our webinar portal which now has a variety of RACE- Phone: (800) 874-0498
approved webinars that are complimentary for AAFP members. You can access the webinar Email: info@catvets.com
portal by logging in to the Member Center. Finally, mark your calendar for our Practice
Management meeting in Lake Tahoe, NV (March 4-6, 2016) and our fall conference in ExECuTIvE DIRECToR Heather O’Steen
Washington, DC (November 3-6, 2016). MANAGING DIRECToR Richard Alampi
SENIoR MEETINGS
We couldn’t accomplish our goals without the generous support of our sponsors. The CooRDINAToR
Tara Dalrymple
AAFP Board of Directors and members would like to thank Boehringer Ingelheim, Bayer MANAGER, MARkETING &
CoMMuNICATIoNS
Crystal DeCotiis
HealthCare, Elanco, Hill’s Pet Nutrition, Idexx Laboratories, Royal Canin, Merial, Zoetis,
Wedgewood Pharmacy, Nexvet, Dentalaire, Midmark, The International Cat Association, CoMMuNICATIoN
CooRDINAToR
Cory Orlando
Purina, and Winn Feline Foundation.
MEMBERShIP &
CAT FRIENDLY PRACTICE Carolyn Pacitti
This week promises to be full of education, networking, and time to relax and enjoy both CooRDINAToR
this wonderful city and spend time with your colleagues and friends. It’s my pleasure as
President, and on behalf of the Board of Directors and the AAFP staff, to wish you a DISCLAIMER:
wonderful time with us in San Diego. The AAFP 2015 Annual Conference Proceedings Book has
been created and produced by the AAFP. The contents of this
book (all presentation content, advertisements, marketing
Best wishes, materials, etc.) have been provided by the conference speakers,
sponsors, and advertisers and does not necessarily reflect the
opinions of the AAFP. The AAFP accepts no responsibility for
Susan Little, DVM any errors or omissions contained within this document.
2015 AAFP President
www.catvets.com/education/ October 1 – 4, 2015 American Association of Feline Practitioners 1

Sponsors:
2015CONFERENCE
We would like to recognize and thank the

following companies for their sponsorships.
Platinum Partnership Sponsor Diamond Partnership Sponsor
Sponsoring the Conference Proceedings, Sponsoring the Exhibitors’ Welcome Reception and
Meet & Greet Reception, and ABVP/AAFP Seminar & Social with Drs. Elizabeth Colleran,
Conference Tote Bags William Folger, Susan Little, and Margie Scherk
Gold Partnership Sponsor Silver Partnership Sponsor

Sponsoring the Offsite Event Sponsoring the Food for Thought Luncheon and
and Hotel Key Cards Speakers Drs. S. Dru Forrester and Jane Robertson
Silver Partnership Sponsor Silver Partnership Sponsor Silver Partnership Sponsor

Sponsoring a Lunch & Learn and Speakers Sponsoring a Lunch & Learn with Sponsoring the Conference
Drs. Michael Lappin and Lorrie Gaschen Dr. Susan Little Waterbottles
A SANOFI COMPANY
Conference Sponsor Conference Sponsor Conference Sponsor

Sponsoring a Lunch & Learn with Dr. Michael Sponsoring Speaker Dr. Erika Krick Sponsoring Speaker Dr. Zoe Lenard
Petty and General Session on Pain Management
Guidelines with Drs. Michael Petty and Ilona Rodan
Conference Sponsor Conference Sponsor Conference Sponsor

Co-sponsoring the Dental Masterclass Co-sponsoring the Dental Masterclass Sponsoring the Para-professional Track
and Hands-on Lab and Hands-on Lab
Conference Sponsor Conference Sponsor

Sponsoring the Notepad & Pen Sponsoring Speaker Dr. Annette Smith
2 American Association of Feline Practitioners October 1 – 4, 2015 www.catvets.com/education

2015
3 WORLD FELINE
rd
October 1 - 4, 2015 ■ Manchester Grand Hyatt ■ San Diego, CA
VETERINARY
CONFERENCE THURSDAY, OCTOBER 1, 2015 5 Additional CE Hours
Pre-conference Day Sessions
PRE-CONFERENCE SESSIONS
Separate registration required
Sponsored by
Food for Thought Luncheon in Grand Hall D
Pre-conference registration required
Chronic Kidney Disease: Making the Most of Early Diagnosis 11:15 – 12:45 pm
Dr. S. Dru Forrester and Dr. Jane Robertson
Sponsored by
ABVP/AAFP Seminar & Social in Grand Hall C 1:00 – 5:30 pm
Included in Pre-conference registration
End of Life Issues in Feline Medicine 1:00 – 2:00 pm

Dr. William Folger
Death & Dying: Feline Euthanasia in the Clinical Setting 2:00 – 3:00 pm
Dr. Elizabeth Colleran
Sponsored by
Seminar & Social Refreshment Break 3:00 – 3:30 pm
Controversies Surrounding Protein in Feline Nutrition

Dr. Margie Scherk 3:30 – 4:30 pm
Emerging Infectious Diseases 4:30 – 5:30 pm

Dr. Susan Little
Sponsored by
WELCOME RECEPTION in Outdoor Courtyard 5:30 – 7:00 pm
All attendees invited
Track Descriptions
Tracks A & B - This conference offers two veterinary concurrent tracks that allow attendees the opportunity to customize their learning
experience. Both tracks offer cutting-edge feline research and the latest information in feline medicine. You can choose to follow one
track exclusively — or you can jump between tracks, based on your own interests and needs.
Para-professional Track - This track is designed for technicians, practice managers, and other hospital staff who consult with clients.

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www.catvets.com/education/October
October
1 –14,– 4,
2015
2015American
AmericanAssociation
Association
of of
Feline
Feline
Practitioners
Practitioners 55
2015
3 WORLD FELINE
rd
VETERINARY
CONFERENCE FRIDAY, OCTOBER 2, 2015
COMBINED TRACK
Grand Hall C & D
7:30 – 8:00 am CONTINENTAL BREAKFAST in Grand Hall Foyer

Included in your registration
President’s Address
8:00 – 8:10 am Dr. Susan Little
8:10 – 8:35 am General Session: Recent Compelling and Clinically Relevant JFMS Updates
Dr. Margie Scherk
General Session: Feline Pain Management Guidelines Sponsored by

8:35 – 10:00 am Dr. Michael Petty and Dr. Ilona Rodan
10:00 – 10:45 am NETWORKING REFRESHMENT BREAK in Exhibit Hall

TRACK A TRACK B
Grand Hall C Grand Hall D
Thoracic Ultrasound: Feline Thoracic Feline Thoracic Radiographs: Interpretive
10:45 – 11:35 am Disease Principles & Normal Variations
Dr. Livia Benigni Dr. Lorrie Gaschen Sponsored by
Ultrasound of Feline Gastrointestinal, Improve Your Radiographic

11:40 – 12:30 pm Hepatic, & Pancreatic Diseases Interpretation of the Feline Abdomen
Dr. Livia Benigni Dr. Lorrie Gaschen
LUNCH in Exhibit Hall

12:30 – 2:00 pm
12:45 - 1:45 pm Lunch & Learn: Sponsored by
Updates in Pain Management, Dr. Michael Petty - Hillcrest A

Imaging: Feline Urinary Tract Disease Obstructed or Not? Get the Most from
2:00 – 2:50 pm Dr. Livia Benigni Abdominal Radiographs
Dr. Lorrie Gaschen Sponsored by
Dental Radiography Updates Improve Your Interpretation of

2:55 – 3:45 pm Dr. Brook Niemiec Radiographic Pulmonary Patterns in the Cat
Dr. Lorrie Gaschen
3:45 – 4:15 pm NETWORKING REFRESHMENT BREAK in Exhibit Hall

Feline Bones: Musculoskeletal Review Radiographic Interpretation of Heart

4:15 – 5:05 pm Dr. Zoe Lenard Sponsored by
Disease in Cats
Do Cats Have 9 Lives? Imaging Special Sonographic Features

5:10 – 6:00 pm in Cases of Feline Trauma of the Feline Abdomen
Dr. Zoe Lenard Dr. Lorrie Gaschen
Sponsored by
6:00 – 7:00 pm EXHIBITORS’ HAPPY HOUR RECEPTION in Exhibit Hall

2015
3 WORLD FELINE
rd
VETERINARY
CONFERENCE SATURDAY, OCTOBER 3, 2015
TRACK A TRACK B PARA-PROFESSIONAL

Grand Hall C Grand Hall D Cortez Hill A
FUN RUN
Separate registration required 6:30 am
BREAKFAST in Exhibit Hall

Co-sponsored by Co-sponsored by
7:30 – 8:30 am
8:15 am – 12:15 pm Feline Dental Radiology Masterclass
and Hands-on Lab #1 Separate registration required
Imaging of Round Cell MRI & CT for Feline Understanding the Cat &
Neoplasia in the Cat Practitioners Feline-friendly Handling: Part 1 8:30 – 9:20 am
Dr. Zoe Lenard Sponsored by Dr. Livia Benigni Dr. Ilona Rodan Sponsored by
CT of the Feline Choosing & Using Radiology Understanding the Cat

Head & Ultrasound Equipment & Feline-friendly Handling: Part 2 9:25 – 10:15 am
Dr. Zoe Lenard Dr. Livia Benigni Dr. Ilona Rodan
NETWORKING REFRESHMENT BREAK in Exhibit Hall

10:15 – 10:45 am
10:20 – 10:45 am AAFP Membership Meeting – Torrey Hills A
Managing the Feline Cancer Patient: Part 1 Kitties in Crisis: Emergency

Dr. Erika Krick Sponsored by Care for Cats Sponsored by 10:45 – 11:35 am
Ms. Erica Mattox
Managing the Feline Cancer Patient: Part 2 How to Survive the Hospitalized
Dr. Erika Krick Cat: Feline Patient Care 11:40 – 12:30 pm
Ms. Erica Mattox

12:45 – 1:45 pm Lunch & Learn: Sponsored by
Update on Feline Anaplasmosis, Dr. Michael Lappin – Hillcrest A

12:30 – 2:00 pm
1:20 – 1:50 pm ABVP: Is It For Me? – Grand Hall C
1:30 – 5:30 pm Feline Dental Radiology Masterclass
Oral Tumors in Cats: Hope Feline Lymphoma Kitties vs. Kidneys: Feline
for the Future Sponsored by
Dr. Erika Krick
Sponsored by
Kidney Disease Sponsored by 2:00 – 2:50 pm
Dr. Annette Smith Ms. Erica Mattox
Management of Feline Neoplastic Effusions Trouble in the Urethra: Feline

Large-cell Lymphoma Updates Dr. Erika Krick Lower Urinary Tract Disease 2:55 – 3:45 pm
FREE TIME
3:45 – 6:30 pm
3:50 – 4:45 pm Cat Friendly Practice Forum – Grand Hall D
Sponsored by
Polynesian Paradise Offsite Event 6:30 – 10:30 pm

2015
3 WORLD FELINE
rd
VETERINARY
CONFERENCE SUNDAY, OCTOBER 4, 2015
TRACK A TRACK B

Included in your registration 7:30 – 8:30 am
ABVP Breakfast for Diplomates in Cortez A
Secrets to Improve Quality-of-Life for Chemotherapy Drugs

Cats with Cancer Dr. Erika Krick Sponsored by 8:30 – 9:20 am
Dr. Greg Oglivie
Care Beyond a Cure: Diagnostic Secrets & Less Common Cat Cancers
the Cancer Patient Dr. Erika Krick 9:25 – 10:15 am
Dr. Greg Oglivie
NETWORKING REFRESHMENT BREAK in Exhibit Hall 10:15 – 10:45 am

Injection Site Associated & Other Soft Tissue Top Oncology Mistakes & How to Avoid
Sarcomas: New Advances for 2015 Them: Part 1 10:45 – 11:35 am
Dr. Greg Oglivie Dr. Sue Ettinger
10 Best Kept Secrets for Treating Cats Top Oncology Mistakes & How to Avoid
with Cancer Them: Part 2 11:40 – 12:30 pm


12:30 – 1:45 pm
Diarrhea Dilemma: What We Think We Know
About Treatment of IBD, Dr. Susan Little - Hillcrest A
Kitty Oncologic Emergencies: HELP!!! See Something, Do Something. Why wait?

Dr. Greg Oglivie Aspirate.TM 1:45 – 2:35 pm
Dr. Sue Ettinger
The Secret Weapon: Polyunsaturated Practical Take-home Tips for Managing

Fatty Acids & Cancer: Advances for 2015 Feline Cancer Patients in Your Practice 2:40 – 3:30 pm
Conclusion of Conference 3:30 pm

Distinguished Speakers:
2015CONFERENCE
Livia Benigni, DVM, MRCVS, CertVDI, PGCertAP, DECVDI

The Royal Veterinary College, University of London
Dr. Benigni graduated in 1997 from the University of Pisa in Italy. She was an intern in Internal Medicine (Cardiology) at the National Veterinary School of Alfort (Paris,
France) and a Diagnostic Imaging Resident at the Royal Veterinary College (University of London, UK). She obtained the Diploma of the European College of Veterinary
Diagnostic Imaging in 2005. Dr. Benigni has worked as a radiologist at The Royal Veterinary College and in private practice. She has over a decade of experience in small
animal radiology, ultrasound, computed tomography, and magnetic resonance. Dr. Benigni has published over 30 peer-reviewed articles and contributed to multiple
veterinary imaging textbooks. She has been an invited speaker to many national and international meetings and actively contributes to the continuous development of the
veterinary profession in the UK and abroad.
Elizabeth Colleran, DVM, MS, DABVP (Feline) Sponsored by

Owner, Chico Hospital for Cats, Chico, CA and Cat Hospital of Portland, Portland, OR
Dr. Colleran is a 1990 graduate of Tufts University School of Veterinary Medicine. She is the owner of two feline exclusive practices, one in Portland, Oregon founded in
2003 and the second in Chico, California founded in 1998. She received a Master’s in Animals and Public Policy in 1996 from Tufts University School of Veterinary
Medicine. Dr. Colleran is an ABVP Diplomate in Feline Practice. She is also a Past President of the AAFP and member of the AAFP’s Cat Friendly Practice Task Force.
Sue Ettinger, DVM, DACVIM (Oncology)

Animal Specialty Center, Yonkers, NY
Dr. Ettinger is a board certified veterinary medical cancer specialist. She graduated from Cornell University College of Veterinary Medicine in 1998. Dr. Ettinger then
completed a one-year internship in small animal medicine and surgery followed by a residency in medical oncology at The Animal Medical Center in New York City.
She is a Diplomate of the American College of Veterinary Internal Medicine (Oncology) and 1 of only 300 board-certified veterinary specialists in medical oncology
in North America. Dr. Ettinger is currently head of the Oncology Department at the Animal Specialty Center in Yonkers, NY. Also known as “Dr. Sue Cancer Vet,” she is
a book author, radio co-host, and Certified Veterinary Journalist. Dr. Ettinger is the co-author of the Second Edition of The Dog Cancer Survival Guide, and she co-hosts
The Pet Cancer Vet, an internet radio show on radiopetlady.com. From 2011 to 2014, Dr. Ettinger was a regular contributor to the blog, dogcancerblog.com. She lives
in Westchester, NY with her husband, a veterinary internist, their two sons, their goofy black Labrador, Matilda, and their dog-loving orange cat, Jeter. Dr. Ettinger
is passionate about raising cancer awareness, and she has developed See Something, Do SomethingTM to promote early cancer detection and diagnosis. She can be
found on social media at facebook.com/DrSueCancerVet and @DrSueCancerVet on Twitter.
William Folger, DVM, MS, DABVP (Feline) Sponsored by

Memorial Cat Hospital, Houston, TX
Dr. William (Bill) Folger, has been involved in animal welfare for over 35 years. He has Biology degrees from the University of the South and Texas A&M University, and
received his DVM from the University of Tennessee, College of Veterinary Medicine. Dr. Folger has been a Diplomate of the American Board of Veterinary Practitioners
(ABVP), Feline Specialty, since 1998, and is the Hospital Director and Founder of Memorial Cat Hospital in Houston. He is the current Feline Regent for the ABVP, the
founding Chair of the Feline Welfare Committee for the American Association of Feline Practitioners, and is currently President of the Society for Veterinary Medical Ethics.
S. Dru Forrester, DVM, MS, DACVIM Sponsored by

Hill’s Pet Nutrition
Dr. Forrester received her DVM from Auburn University in 1985 and completed an internship, residency, and MS degree at Texas A&M University. She was a faculty
member at Virginia Tech (1990-2003) and Western University (2003-2005) where she served as Full Professor as well as many other administrative positions. She
has numerous publications including journal articles, book chapters, research abstracts, and has presented at conferences throughout the world. Dr. Forrester’s
passion is facilitating the learning of others and she has received numerous awards recognizing her teaching excellence. Her clinical interests include lower urinary tract
disorders, kidney disease, and clinical nutrition. She joined Hill’s Pet Nutrition in 2005 and currently serves as the Director of Global Scientific Affairs. Dr. Forrester is
also an adjunct faculty member in the Department of Clinical Sciences at Kansas State University and a Fellow of the Mark Morris Institute.
Lorrie Gaschen, PhD, DVM, Dr.med.vet, DECVDI Sponsored by

Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University
Dr. Gaschen received her DVM from the University of Florida, was in private practice in Florida for two years after which time she completed a diagnostic imaging residency
at the University of Bern in Switzerland and became a diplomate of the European College of Veterinary Diagnostic Imaging. She received her PhD in renal transplant
imaging in animal models at the University Medical School in Utrecht then returned to the University of Bern where she became an associate professor. Her major
interests are in gastrointestinal ultrasound, and vascular imaging, as well as MRI. Currently, she is a full professor and section chief at the Louisiana State University,
Section of Diagnostic Imaging, as well as being the new Associate Dean for Diversity and Faculty Affairs. She has authored numerous publications and book chapters
mainly in the field of ultrasound, vascular, and gastrointestinal imaging where she has done the majority of her research. She is a frequent national and international
lecturer and conducts abdominal ultrasound labs both at conferences and at LSU.
Erika Krick, VMD, DACVIM (Oncology) Sponsored by

Assistant Professor of Oncology, University of Pennsylvania, School of Veterinary Medicine
Dr. Krick received her undergraduate (BA) degree in Biology from Swarthmore College in Swarthmore, Pennsylvania, and her veterinary training at the University of
Pennsylvania, School of Veterinary Medicine. She completed a rotating internship in Small Animal Medicine and Surgery and a Residency in Medical Oncology at the
University of Pennsylvania, School of Veterinary Medicine. She joined the veterinary faculty at UPenn in 2009 and is currently an Assistant Professor of Oncology and
Co-Service Head of the Comprehensive Cancer Care Service there. Currently she co-manages the Comprehensive Cancer Care Service, provides didactic lectures in
small animal oncology topics to third year veterinary students, organizes and facilitates communication skills labs for first and third year veterinary students, organizes a
third year student course focused on developing communication skills, trains medical oncology residents, and conducts focused research in the area of feline lymphoma
and cancer cachexia. She is also actively involved in several clinical trials evaluating novel therapies for different types of cancer in dogs. She has authored several
research manuscripts and book chapters regarding lymphoma in cats.
Distinguished Speakers:
2015CONFERENCE
Michael Lappin, DVM, PhD, DACVIM Sponsored by

Professor of Small Animal Internal Medicine, Colorado State University
After graduating from Oklahoma State University in 1981, Dr. Lappin completed a rotating internship in small animal medicine and surgery at the University of
Georgia. After 2 years in a small animal practice in Los Angeles, he returned to the University of Georgia where he completed a small animal internal medicine
residency and a PhD in Parasitology. Dr. Lappin was board-certified by the American College of Veterinary Internal Medicine in 1987. He is currently Professor of
Small Animal Internal Medicine at the College of Veterinary Medicine and Biomedical Sciences at Colorado State University. Dr. Lappin studies feline infectious and
immune-mediated diseases and has written over 250 primary research manuscripts and book chapters. His principal areas of interest are prevention of infectious
diseases, the upper respiratory disease complex, infectious causes of fever, infectious causes of diarrhea, and zoonoses of cats. Dr. Lappin is on the editorial
board of Feline Medicine and Surgery and Compendium for Continuing Education for the Practicing Veterinarian and is the editor of the textbook, Feline Internal
Medicine Secrets. Dr. Lappin has received the Beecham Research Award and the Norden Distinguished Teaching Award. Dr. Lappin is the Kenneth W. Smith
Professor in Small Animal Clinical Veterinary Medicine at Colorado State University and is currently the Assistant Department Head for Research. Dr. Lappin is the
director of the “Center for Companion Animal Studies,” which supports clinical research for faculty and students and utilizes only naturally occurring models of
disease or research animals that can be adopted. He was selected to receive the European Society of Feline Medicine International Award 2008 for Outstanding
Contribution to Feline Medicine, the Winn Feline Research Award in 2009, and was named an Oklahoma State University Distinguished Professor in 2010.
Zoe Lenard, BVSc (Hons), FANZCVS (Radiology) Sponsored by

Perth Veterinary Specialists, Western Australia
Following graduation from the University of Sydney with a Bachelor of Veterinary Science (1999), Dr. Lenard worked in companion animal practice in inner Sydney
for 4 years. Dr. Lenard undertook a residency in Diagnostic Imaging (2003-2006, Murdoch University) and became a Fellow of the Australian & New Zealand
College of Veterinary Scientists (Radiology) in 2007. She has worked in academic practice as a Senior Lecturer at Murdoch University, before moving to private
practice where she is a Director of the Veterinary Imaging Centre & Perth Veterinary Specialists, Western Australia’s first private practice referral center. Her
interests include abdominal ultrasonography and the conversion of vet practice to “digital” imaging and cross sectional imaging. Dr. Lenard is well-connected
within the diagnostic imaging community, previously serving as President of the Radiology Chapter of the Australian College of Veterinary Scientists, and currently
on the executive board of the Australasian Association of Veterinary Diagnostic Imaging. Dr. Lenard has trained residents, been involved with examination at Board
Level, and regularly provides continuing education to vets in Australia, New Zealand, and Asia.
Susan Little, DVM, DABVP (Feline) Sponsored by

Bytown Cat Hospital, Ottawa, Canada
Dr. Susan Little received her BSc from Dalhousie University (Nova Scotia, Canada) and her DVM from the Ontario Veterinary College, University of Guelph. She
has been in feline practice since 1990 and achieved board certification in Feline Practice in 1997. She is part owner of two feline specialty practices in Ottawa,
Canada. She is a board member and current President of the American Association of Feline Practitioners (2015) as well as a past board member and Past
President of the Winn Feline Foundation. Dr. Little joined the National Board of Veterinary Medical Examiners in 2015 representing the American Animal Hospital
Association. She is a peer reviewer for veterinary journals as well as the author of many journal articles. Dr. Little is the recipient of the Canadian Veterinary
Medical Association’s Small Animal Practitioner Award (2010), the NAVC Small Animal Speaker of the Year Award (2013), and the International Society of Feline
Medicine/Hill's Pet Nutrition Award for outstanding contributions to feline medicine (2013). She is the editor and co-author of The Cat – Clinical Medicine and
Management (Elsevier, 2012) and Volume 7 of August's Consultations in Feline Internal Medicine (Elsevier, 2015).
Erica Mattox, CVT, VTS (ECC) Sponsored by

WestVet, Boise, ID
Erica is the Patient Care Director at WestVet in Boise, Idaho and passed her VTS exam in 2009 to become the first VTS (ECC) in Idaho. She has been the President
of the Idaho Society of Veterinary Technicians and Assistants since 2009. Erica has instructed for both the College of Southern Idaho and Brown Mackie’s
Veterinary Technology programs and presents CE monthly for WestVet and quarterly for the ISVTA. She holds a position on the Idaho Veterinary Medical
Association Board as the first CVT representative. In 2012, she received the Presidential Citation Award from the IVMA for outstanding performance as well as
won the Best Technician Case Report Award at IVECCS. She is on the AVECCT exam committee and Nursing Care committee. Erica is very passionate about
emergency medicine and the profession of Veterinary Technology in general.
Brook Niemiec, DVM, DAVDC, DEVDC, FAVD

Southern California Veterinary Dental Specialists and Oral Surgery, San Diego, CA
Dr. Niemiec is a 1994 graduate of the University of California, Davis. He is a Board Certified Specialist in Veterinary Dentistry by the American Veterinary Dental
College as well as the European Veterinary Dental College and a Fellow in the Academy of Veterinary Dentistry. He is immediate Past President of the Academy
of Veterinary Dentistry as well as its representative to the World Small Animal Veterinary Association. He is Chief of Staff of Southern California Veterinary Dental
Specialties with offices in Santa Barbara, San Diego, Irvine, Ontario, and Murrieta California, as well as Las Vegas, Nevada and New Orleans. As an advocate for
oral health he is a regular speaker on the local, national, and international levels. In addition, he has authored many articles, chapters, and books including the
recently published Small Animal Dental Oral, and Maxillofacial Disease: A Color Handbook and Veterinary Periodontology. Through Practical Veterinary Publishing
he has published veterinary dental specific titles including: extractions, endodontics, orthodontics, dental emergencies, and restorations. He founded the premier
veterinary dental telemedicine website vetdentalrad.com, which has produced instructional videos and educational posters. Finally, he coordinates the San Diego
Vet Dental Training Center which has 3-4 meetings a year covering basic and intermediate veterinary dentistry.

Distinguished
DistinguishedSpeakers:
Speakers:
2015CONFERENCE
2015CONFERENCE
Greg
GregOgilvie,
Ogilvie,DVM,
DVM,DACVIM
DACVIM(Internal
(Internal
Medicine,
Medicine,
Oncology),
Oncology),
ECVIM-CA
ECVIM-CA
Oncology
Oncology
Professor
Professor and andDivision
Division Director
Director of of Veterinary
Veterinary Oncology,
Oncology, University
University of of
California-San
California-San Diego,
Diego, Moores
Moores Cancer
Cancer Center,
Center, and and Director
Director
of ofthetheAngel
Angel CareCare Cancer
Cancer Center,
Center, California
California Veterinary
Veterinary Specialists
Specialists
Dr.Dr.
Ogilvie
Ogilviedeveloped
developed hishis
longlong
lovelove
for for
all all
things
things
feline
feline in Colorado
in Colorado where
wherehe he
graduated
graduatedveterinary
veterinaryschool
schoolat the
at theColorado
Colorado State
State
University
University
before
before
doingdoingan an
NIHNIH
research
research fellowship
fellowshipat the
at the
University
University
of Wisconsin,
of Wisconsin, residency
residency at Tufts
at TuftsUniversity
Universityandand
professorships
professorships at the
at the
University
University
of Illinois,
of Illinois,
Colorado
ColoradoState
State
University,
University,andandat the
at the
medical
medicalschool
school
at l'Université
at l'UniversitéFrançois
François Rabelais
Rabelais in Tours,
in Tours, France
France before
beforejoining
joining
thethe
faculty
faculty
at the
at the
University
University of California
of California
andand at California
at California
Veterinary
Veterinary Specialists
Specialists
in in
feline
feline
friendly
friendly
SanSanDiego.
Diego.WhenWhenDr.Dr.
Ogilvie
Ogilvie
is not
is not
caring
caring for for
kitties
kitties
andandtheir
their
families,
families,
he he
teaches
teachesinterns,
interns,
residents,
residents, andand
veterinary
veterinary students
studentsabout
aboutall all
things
things
feline.
feline.
Dr.Dr.
Ogilvie
Ogilviealsoalso
works
workswithwith
somesome of the
of the
mostmostbrilliant
brilliantresearchers
researchers in the
in the
world
worldto develop
to developnovel,
novel,
newnew compassionate
compassionate cancer
cancer therapies
therapiesfor for
catscats
andandpeople.
people.He Hehashas
co-authored
co-authored fourfour
books
books
including
including hishis
favorite,
favorite,
Feline
FelineOncology:
Oncology: Compassionate
Compassionate Care
Care
for for
Cats
Cats
withwith
Cancer.
Cancer. TheThe newest
newestbook bookjustjust
released
releasedaround
aroundthetheworld
world
is is
entitled
entitled
A Compassionate
A Compassionate Guide
Guide
to Cancer
to Cancer Care.
Care.
It promises
It promises to unleash
to unleash somesomespecial
special
feline
feline
secrets.
secrets.ThisThis
fifthfifth
generation
generation Colorado
Colorado native
native
hashasalsoalso
written
written
overover
200200scientific
scientificarticles
articles
andandchapters
chaptersas aswellwell
as as
overover120120 scientific
scientific
abstracts
abstracts andand
posters.
posters.He He
hashasbeenbeen
awarded
awarded twotwo
international
international patents,
patents,
overover
10 10million
million
dollars
dollars
in research
in research grants
grantsandand
endowments
endowments as asa principal
a principalor co-investigator,
or co-investigator, andandis the
is the
recipient
recipientof many
of many teaching
teaching andand research
research awards.
awards.Dr.Dr.
Ogilvie
Ogilvie
hashaslectured
lecturedin scores
in scores
of countries
of countries about
aboutthethe
mysteries
mysteriesof kitty
of kitty
cancer
cancerto many
to many thousands
thousands of students,
of students, veterinarians,
veterinarians,physicians,
physicians, andand scientists
scientistsin Africa,
in Africa,
Australia,
Australia,
New NewZealand,
Zealand, Asia,
Asia,
Europe,
Europe,thetheMiddle
MiddleEast,
East,
South
South America,
America, andand
NorthNorth
America.
America.
Mike
MikePetty,
Petty,DVM,
DVM,CVPP,
CVPP,CVA,
CVA,CCRT,
CCRT,DAAPM
DAAPM Sponsored
Sponsored
by by
Arbor
ArborPointe
Pointe Veterinary
Veterinary Hospital,
Hospital, Canton,
Canton, MIMI
Dr. Dr.
Petty
Petty
is currently
is currently
thethe
owner
ownerof Arbor
of Arbor
PointPoint
Veterinary
Veterinary
Hospital
Hospital
andand
Animal
Animal
PainPain
Center
Center
in Canton,
in Canton,Michigan
Michiganwhere
wherehe hehashas
beenbeen
a life-long
a life-long
resident.
resident.
He He
is certified
is certified
in in
acupuncture,
acupuncture,rehabilitation,
rehabilitation,
andand
is aisCertified
a Certified
Veterinary
Veterinary
PainPain
Practitioner.
Practitioner.
From
From
2011-2013,
2011-2013, Dr. Dr.
Petty
Petty
waswas
thethe
President
President of the
of the
International
InternationalVeterinary
Veterinary
Academy
Academy of Pain
of Pain
Management.
Management. He He
is the
is the
author
author
of two
of two
books,
books,
Dr. Dr.
Petty’s
Petty’s
PainPain
Relief
Relief
for for
Dogs:
Dogs:
A Complete
A Complete Guide
Guide(publish
(publish
datedate
January
January 2016)
2016)andand
Dr. Dr.
Petty’s
Petty’s
PainPain
Relief
Relief
for for
Cats:
Cats:
A A
Complete
CompleteGuide
Guide
(publish
(publishdatedate
TBD).
TBD).He He
alsoalso
co-authored
co-authored thethe
AAFP/AAHA
AAFP/AAHA 2015
2015PainPain
Management
Management Guidelines.
Guidelines.
He He
liveslives
on on
a small
a small
horsehorse
farm
farm
withwith
hishis
wifewife
andand
twotwo
daughters,
daughters,
along
along
withwith
a menagerie
a menagerie of animals
of animals
fromfrom
large
large
(horses)
(horses)
to small
to small
(hedgehog).
(hedgehog).
Jane
JaneRobertson,
Robertson,DVM,
DVM,DACVIM
DACVIM Sponsored
Sponsored
by by
IDEXX
IDEXX Laboratories
Laboratories
Dr. Dr.
Robertson
Robertsonreceived
received herher
DVMDVMfromfrom
thethe
Ontario
Ontario
Veterinary
VeterinaryCollege
College
at the
at the
University
University
of Guelph
of Guelph
in Canada
in Canadain 1992.
in 1992.
SheSheworked
workedin mixed-animal
in mixed-animal andand
small-animal
small-animal
practice
practice
before
before
completing
completing a small-animal
a small-animal internship
internship
at the
at the
same
sameinstitution
institution
in 1994.
in 1994.
Dr. Dr.
Robertson
Robertson
completed
completedherher
medicine
medicine
residency
residency
at University
at University
of California,
of California,
Davis,
Davis,
andand
became
becameboard-certified
board-certified by the
by the
American
AmericanCollege
College
of Veterinary
of Veterinary
Internal
Internal
Medicine
Medicinein 1998.
in 1998.
SheShe
practiced
practiced
in ainbusy
a busy
referral
referral
hospital
hospital
before
before
joining
joining
IDEXX
IDEXX
as aasmedicine
a medicine
consultant
consultant
in 2000.
in 2000. Dr. Dr.
Robertson
Robertsonis currently
is currently
Director
Director
of Internal
of Internal
Medicine
Medicinefor for
IDEXX
IDEXX
Laboratories.
Laboratories.
SheShe
enjoys
enjoys
speaking
speakingabout
about
kidney
kidney
disease,
disease,
endocrinology,
endocrinology,
pancreatitis,
pancreatitis,
andand
thethe
clinical
clinical
utility
utility
of real-time
of real-time
PCR.PCR.
Ilona
Ilona
Rodan,
Rodan,
DVM,
DVM,
DABVP
DABVP
(Feline)
(Feline) Sponsored
Sponsored
by by Sponsored
Sponsored
by by
Cat Cat
CareCare Clinic,
Clinic,Madison,
Madison, WIWI
Dr. Dr.
Rodan
Rodanis the
is the
Behavior
Behavior Consultant
Consultant andandan an
Associate
Associateat the
at the
CatCat
CareCare
Clinic
Clinic
in Madison,
in Madison, Wisconsin
Wisconsin
having
having
soldsold
thethe
practice
practice
in February
in February
2015
2015after
after
overover
28 28
years
years
of of
ownership.
ownership. SheSheis ABVP
is ABVPcertified
certified
in feline
in feline
practice
practice
since
since
1995,
1995,andandstarted
startedFeline-Friendly
Feline-Friendly Consultations
Consultations
in 2010
in 2010to help
to help
veterinarians
veterinarians
make
maketheir
their
handling,
handling,environment,
environment,
andand
medicine
medicine moremorefeline-friendly.
feline-friendly.
Dr. Dr.
Rodan
Rodanis aisPast
a Past
President
Presidentof the
of the
AAFP,AAFP,
andand hashasco-chaired
co-chaired
a number
a numberof guidelines
of guidelines
including
including
thethe
AAFP
AAFP
Feline-Friendly
Feline-Friendly Handling,
Handling,
AAFPAAFPFeline
Feline
Environmental
Environmental Needs,
Needs,andandthethe
AAHA/AAFP
AAHA/AAFP PainPain
Management
Guidelines. In 2005,
In 2005,
sheshe
waswas
awarded
awarded thethe
AVMAAVMAAnimal
Animal
Welfare
Welfare
Award
Award for for
herher
leadership
leadership
andand
contributions
contributionsto advancing
to advancing feline
feline
welfare.
welfare.Veterinary
Veterinarybehaviorist
behavioristDr. Dr.
Sarah
Sarah Heath
Heathandand Dr. Dr.
Rodan
Rodan
have
have
co-edited
co-editedthethe
book,
book,
Feline
Feline
Behavioral
Behavioral
Health
Health
andand Welfare
Welfare
which
which
waswaspublished
published thisthis
month,
month,willwill
debut
debutin September,
in September, andand
is available
is availablefor for
thethe
firstfirst
timetime
at this
at this
conference.
conference.
Margie
MargieScherk
ScherkDVM,
DVM,DABVP
DABVP(Feline)
(Feline) Sponsored
Sponsored
by by
catsINK,
catsINK, Vancouver,
Vancouver, BCBC
Dr. Dr.
Scherk
Scherk
graduated
graduated
fromfrom
thethe
Ontario
Ontario Veterinary
VeterinaryCollege
College
in 1982.
in 1982.
In 1986
In 1986 shesheopened
openedCats
Cats
Only
Only
Veterinary
Veterinary
Clinic
Clinic
in Vancouver,
in Vancouver,
practicing
practicing there
there
untiluntil
20082008
when
whensheshe
retired
retired
from
from
regular
regular
practice.
practice.
While
Whilein practice,
in practice,
sheshepublished
published several
several
clinical
clinical
trials,
trials,
including
including
thethe
firstfirst
paper
paper
on on
transdermal
transdermal fentanyl
fentanylpatch
patchin veterinary
in veterinary
medicine.
medicine.
SheShe
hashas
written
written
manymany
book
book
chapters,
chapters,
co-edits
co-editsthethe
Journal
Journalof Feline
of FelineMedicine
MedicineandandSurgery,
Surgery,andand
hashas
served
servedextensively
extensively
on on
committees
committees withwith
thetheAAFP,
AAFP,
North
North
American
American
VetVet
Licensing,
Licensing,
Winn
Winn
Feline
Feline
Foundation,
Foundation,
WSAVA,
WSAVA, andand
ABVP.ABVP.
SheSheis aisPaw
a Paw
Project
Projectadvocate,
advocate,hoping
hoping
to end
to end declawing
declawingin Canada.
in Canada.SheShecontinues
continues to assist
to assist
colleagues
colleagueswithwith
case
case
management
management andand
enjoys
enjoys
teaching
teaching
all things
all things
feline,
feline,
including
including
improving
improving
interacting
interactingwithwith
cats,
cats,
analgesia,
analgesia, nutrition,
nutrition,
andand
thethe
peculiarities
peculiarities
of the
of the
feline
feline
digestive
digestivesystem.
system.
Annette
AnnetteSmith,
Smith,DVM,
DVM,MS,
MS,DACVIM
DACVIM(Oncology
(Oncology
&&SAIM)
SAIM)
Sponsored
Sponsored
by by
Distinguished
Distinguished Lowder
Lowder Professor
Professor in in
Oncology,
Oncology, Auburn
Auburn University,
University, Auburn,
Auburn, ALAL
Dr. Dr.
Smith
Smith
completed
completedthree
three
years
years
of the
of the
Biomedical
BiomedicalScience
Science
program
program at Texas
at Texas
A&M A&Mprior
prior
to admission
to admission to the
to the
DVMDVMprogram
program at Texas
at Texas A&M’s
A&M’s College
Collegeof Veterinary
of VeterinaryMedi-
Medi-
cine.
cine.
SheShegraduated
graduated
withwith
honors
honorsin May
in May
1994.1994.
After
After
herher
internship
internshipat the
at the
University
Universityof Illinois,
of Illinois,
sheshejoined
joined
Auburn
AuburnUniversity’s
University’sresidency
residencyprogram
program in 1995.
in 1995.SheShewaswascerti-
certi-
fiedfied
in both
in both
Small
Small
Animal
AnimalInternal
Internal
Medicine
Medicine andand
Oncology
Oncologyin May
in May2000.
2000.While
While
pursuing
pursuing herherresidency
residency training,
training,
sheshe
completed
completed a Master’s
a Master’s degree
degreein Biomedical
in Biomedical Sciences
Sciences
in 2001.
in 2001.SheShe
hashas
served
servedon on
thethe
Auburn
AuburnUniversity
University
faculty
faculty
since
since
1999.
1999. SheShe
currently
currently
is the
is the
Distinguished
Distinguished Lowder
Lowder
Professor
Professorin Oncology
in Oncology andandcoordinates
coordinates Auburn
AuburnUniver-
Univer-
sity’s
sity’s
oncology
oncology
program,
program, which
whichfocuses
focuseson on
a multidisciplinary
a multidisciplinaryteamteamapproach
approach to each
to eachpatient
patient
andand hashasapproximately
approximately 2,500
2,500 petpetvisits
visits
eacheachyear.
year.
Additionally,
Additionally, sheshe
hashas
served
served
on onthethe
advisory
advisory
board
boardfor for
thethe
Auburn
Auburn University
UniversityResearch
Research Initiative
Initiative
in Cancer
in Cancer (AURIC)
(AURIC) since
sinceits its
formation.
formation. Dr.Dr.
Smith
Smithhashascontinued
continued to be
to be
involved
involvedin clinical
in clinical
trials,
trials,
administration,
administration,
andand
translational
translationalresearch
researchto provide
to provide
novel
novel
treatments
treatments andanddiagnostics
diagnostics to patients.
to patients. SheSheis committed
is committed to training
to trainingstudents
students andand
residents
residentsin oncology,
in oncology,withwith
13 13board-certified
board-certified
or actively
or actively
training
training
alumni.
alumni.
SheShe
hashas
been
beena guest
a guesteditor
editor
for for
Veterinary
Veterinary Clinics
Clinics
of North
of NorthAmerica
America(Small
(Small
Animal
Animal Practice),
Practice),
written
written
or co-written
or co-written11 11bookbook
chapters,
chapters,authored
authored
or co-authored
or co-authored more
morethanthan
36 36
peer-reviewed
peer-reviewed articles,
articles,
andand
hashaslectured
lectured locally,
locally,
regionally,
regionally,
nationally,
nationally,
andandinternationally
internationallyon on
topics
topics
relating
relating
to oncology.
to oncology.
1414 American
AmericanAssociation
Association
of of
Feline
Feline Practitioners October
Practitioners October
1 –14,– 2015
4, 2015 www.catvets.com/education
K E Y: A TRACK A
Session Abstracts: B TRACK B
C COMBINED TRACK
THURSDAY, OCTOBER 1, 2015 – Pre-conference Day

11:15 – 12:45 pm Chronic Kidney Disease: Making the Most of Early Diagnosis, Dr. S. Dru Forrester and Dr. Jane Robertson
This presentation provides an evidence-based update on early diagnosis and treatment of chronic kidney disease in cats. It will include a review
of new research findings supporting early diagnosis, and practical tips and strategies to consider for successful implementation of nutritional
management.
1:00 – 2:00 pm End of Life Issues in Feline Medicine, Dr. William Folger
Significant advances in veterinary diagnostic and treatment modalities have been introduced into our practice regimens allowing elegant and
sophisticated techniques to be readily available for treatment of our patients. Just a few decades ago it was very common for the veterinarian to
routinely recommend euthanasia for a constellation of chronic, debilitating conditions many cats suffer at the end of their lives. Because the
emotional bond between the owner and patient is so strong, and the clinical situation so confusing, the owner is unwilling or incapable of critically
evaluating the suffering that the patient may be experiencing or that a treatment modality might produce. These situations are also a principle
contributory factor in compassion fatigue experienced by the attending veterinarian. These concepts will be examined in this presentation.
2:00 – 3:00 pm Death & Dying: Feline Euthanasia in the Clinical Setting, Dr. Elizabeth Colleran
Euthanasia is an act to end suffering, not an act to end life. For many complex reasons, the emotional attachment that many humans develop with
their pets not only equals but also frequently transcends the emotional attachment that they form with humans. This makes the responsibility of
the veterinarian who presides over important decisions regarding quality of life and quality of death quite considerable. Using the experience of
veterinarians who are experts on end of life, data from human therapist studies, and years of experience of a house call euthanasia veterinarian, we
will examine how the client experiences end of life decisions. Managing the unexpected, techniques for improving outcomes, and the challenges of
compassion fatigue will all be examined.
3:30 – 4:30 pm Controversies Surrounding Protein in Feline Nutrition, Dr. Margie Scherk
As obligate carnivores with a different set of nutritional requirements than the omnivorous canine, understanding more about feline nutrition is
a valuable component in caring for cats. It is critical to feed cats not just enough calories, but enough calories from protein. Controversy exists
especially when discussing feeding cats with kidney diseases, but also the role of protein in managing diabetes mellitus and weight loss.
4:30 – 5:30 pm Emerging Infectious Diseases, Dr. Susan Little

Emerging infectious diseases are those that have increased in incidence in the last two decades for a variety of reasons, including changes in
pathogens and expanded ranges. This lecture focuses on several important emerging diseases in the cat, such as new manifestations of
streptococcal infections, invasive aspergillosis caused by a newly recognized species, new viral infections (morbillivirus, influenza A), and more.
FRIDAY, OCTOBER 2, 2015

8:10 – 8:35 am C Recent Compelling and Clinically Relevant JFMS Updates, Dr. Margie Scherk
This session will summarize a selection of topical papers published in the Journal of Feline Medicine & Surgery over the past two years. Get ready
for a speedy, stimulating presentation!
8:35 – 10:00 am C Feline Pain Management Guidelines, Dr. Michael Petty and Dr. Ilona Rodan
Great advances in pain management, especially in the field of feline degenerative joint disease, have occurred in the past few years. Pain
management consists of both pharmacologic and non-pharmacologic modalities, with the latter including environmental modifications to allow the cat
to perform its normal behaviors. Changes in the cat’s normal behavior(s) are the key to recognizing pain. Awareness and recognition of both acute and
chronic pain have greatly increased, and validated feline pain scores are now available. Pain management is a team approach with the client playing
a central role due to the awareness of their individual cat’s normal behaviors. A continuum of care is required which includes anticipation of pain, early
intervention, and evaluation of the individual patient’s response to therapy.
10:45 – 11:35 am A Thoracic ultrasound: Feline Thoracic Disease, Dr. Livia Benigni
This lecture will review the use of ultrasound for investigation of thoracic disease in cats. In some cases thoracic ultrasound may prove a better
alternative to radiology. The advantages and limitations of this imaging modality will be discussed.
B Feline Thoracic Radiographs: Interpretive Principles & Normal Variations, Dr. Lorrie Gaschen
In this session the participant will learn to review the feline thorax from the ground up, where to start and how to prioritize the importance of certain
findings. The pitfalls of interpretation and discussion of normal variants will be presented with numerous case examples.
11:40 – 12:30 pm A ultrasound of Feline Gastrointestinal, hepatic, & Pancreatic Diseases, Dr. Livia Benigni
This lecture will review the role of ultrasound in the diagnosis of feline gastrointestinal, hepatic, and pancreatic diseases. In particular it will focus on
differentiation between inflammatory and neoplastic disease. The use of ultrasound guided biopsy techniques will be discussed.
B Improve Your Radiographic Interpretation of the Feline Abdomen, Dr. Lorrie Gaschen
This session will emphasize how to assess the abdomen from the ground up using a systematic approach. The use of positional radiography and easy-
to-do techniques like compression will be shown so that the veterinarian can immediately apply these in their daily practice.
12:45 – 1:45 pm Lunch & Learn: Updates in Pain Management, Dr. Michael Petty
Do you feel comfortable with your current understanding of acute and chronic pain managements for your feline patients? There will be an update on
old products, new products, and a sneak peek at some products in the pipeline. We will also discuss some off-label protocols of these pain drugs;
protocols that manufacturers cannot tell you.

K E Y: A TRACK A
P PARA-PROFESSIONAL
L LAB
FRIDAY, OCTOBER 2, 2015 continued

2:00 – 2:50 pm A Imaging: Feline urinary Tract Disease, Dr. Livia Benigni
This lecture will review the role of contrast radiology and ultrasound in the diagnosis of feline urinary tract disease with particular emphasis on
urolithiasis and neoplastic diseases.
B obstructed or Not? Get the Most from Abdominal Radiographs, Dr. Lorrie Gaschen
This session will emphasize a systematic assessment of the gastrointestinal tract in the normal cat to underscore how to interpret every part of the
gastrointestinal anatomy. Numerous examples of abnormal bowel from the stomach to the colon will be shown. You will be shown techniques to best
assess the GI tract for obstructive and infiltrative disease.
2:55 – 3:45 pm A Dental Radiography updates, Dr. Brook Niemiec
This lecture will initiate a discussion of new equipment and options for dental radiology. Following this discussion will be a presentation on how to
create quality full mouth dental radiographs in cats focusing on the hard to get images (extraoral view for maxillary premolars and the apices of the
mandibular third molar). Finally, we will troubleshoot common errors.
B Improve Your Interpretation of Radiographic Pulmonary Patterns in the Cat, Dr. Lorrie Gaschen
This session will review how to diagnose air space, air way (bronchocentric), interstitial, and complex pattern of the feline lung. Emphasis will be on how
to create a plan of action based on the lung abnormalities and how to best arrive at a diagnosis using numerous case examples.
4:15 – 5:05 pm A Feline Bones: Musculoskeletal Review, Dr. Zoe Lenard
Cats are not small dogs! Diseases affecting the feline musculoskeletal system have elements that are species-specific but get less space allocated
in radiographic textbooks. This lecture will review diseases of feline bones using case-based examples, including neoplastic disease, degenerative
disease, metabolic disease, and juvenile disease.
B Radiographic Interpretation of heart Disease in Cats, Dr. Lorrie Gaschen
This session will review the normal feline heart and show many examples of the abnormal that can and cannot be diagnosed radiographically. The
limitations of radiography will be shown in case examples as well as how secondary findings are important in the diagnosis of heart disease in cats.
5:10 – 6:00 pm A Do Cats have 9 Lives? Imaging in Cases of Feline Trauma, Dr. Zoe Lenard
Cats have a remarkable ability to survive and bounce-back from serious trauma but understanding accurately the extent of the problem early in the
work-up is vital. This lecture will review the imaging approach to trauma, from selecting the best initial test (radiography, ultrasound, CT) to monitoring
treatment. Examples covered include spinal trauma, urinary tract trauma, subtle fracture disease, and managing imaging in the dyspneic feline.
B Special Sonographic Features of the Feline Abdomen, Dr. Lorrie Gaschen
This session will review the sonographic techniques for the veterinarian to improve their sonographic skills by looking beyond the big organs and
learning how to find the small parts. The technique to find the pancreas, lymph nodes, adrenal glands, ileum and cecum, and pylorus will be shown
with numerous cases.
SATURDAY, OCTOBER 3, 2015

8:15 – 12:15 pm L Feline Dental Radiology Masterclass and Hands-on Lab #1, Dr. Brook Niemiec
Get the most out of dental radiology in your practice. There is something for everyone in this program; from novice new graduates to seasoned
practitioners. This program will begin with a discussion on indications for dental radiographs and a case based lecture on the importance of dental
radiology in small animal veterinary patients. This will include recommendations on how to improve client acceptance of dental radiology. Following
this will be a detailed presentation on achieving high-quality dental radiographic images. Utilizing the “simplified technique” supported by
educational videos, attendees should be able to expose full mouth radiographs. No more trying to determine bisecting angles, we have done the
hard work for you! We will also cover the difficult-to-get images of the maxillary premolars in cats with the near parallel and extraoral techniques.
Next we will fully cover interpretation. In an energetic and highly interactive session, practitioners will learn how to read dental radiographic images.
This will begin with a discussion on determining what teeth were imaged. After this we will interpret actual clinical radiographs of classic as well as
unusual pathology. The second half of the class will be devoted to a hands-on laboratory where attendees will practice and perfect exposing full
mouth dental radiographs. After this presentation, attendees should be comfortable with all facets of veterinary dental radiology while increasing
their financial return from their investment and quality-of-care.
8:30 – 9:20 am A Imaging of Round Cell Neoplasia in the Cat, Dr. Zoe Lenard
Some round cell tumors (e.g. lymphoma) are common in cats; other round cell tumors (e.g. mast cell neoplasia, plasma cell tumors) are rare. All can
have a varied appearance with imaging. This lecture will focus on a clinical review of imaging findings (XR, US, CT/MR) of these types of tumors with
practical tips to help confirm which disease is present.
B MRI & CT for Feline Practitioners, Dr. Livia Benigni
This lecture will provide an introduction to basic reading of MRI and CT images, and give practical information about the importance of these
techniques in feline veterinary medicine. When and how to refer a clinical case for advanced imaging will be discussed.
P understanding the Cat & Feline-friendly handling: Part 1, Dr. Ilona Rodan
Feline fear surrounds the veterinary visit, and is a major cause of decreased veterinary care and a subsequent increase in health problems in cats.
During veterinary visits, feline fear can complicate examination and sample collection, and a healthy cat may have abnormal findings due to the stress
response. Fear does not start at the veterinary practice, but rather surrounds the entire visit. We think of the visit as the short period of time the cat is at
the practice, but the client often thinks about it for weeks before and after the appointment. The cat’s fear and anxiety often escalates at subsequent
appointments. Addressing all sources of fear – the owner’s stressed behavior, the carrier and car ride, the smells, sounds and sights at the veterinary
practice, the handling, and the environment – is not only possible but is the answer to these major issues. Feline-friendly handling is based on an
understanding of the cat and its fears, and provides methods to prevent fear and make veterinary visits in your practice more positive for feline patients,
clients, and the veterinary team.

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K E Y: A TRACK A
B TRACK B
Session Abstracts: C COMBINED TRACK
P PARA-PROFESSIONAL
L LAB
SATURDAY, OCTOBER 3, 2015 continued

9:25 – 10:15 am A CT of the Feline head, Dr. Zoe Lenard
Complex anatomy and small size of the feline head makes imaging this area a challenge. Radiographs can be particularly difficult to obtain and
confusing to interpret. This case-based presentation will review clinical conditions where CT is superior to other tests and show how to get the most
from the scan. Diseases covered will include nasal cavity disease, orbital and retrobulbar disease, nasopharynx/laryngeal disease, and diseases of
the ear.
B Choosing & using Radiology & ultrasound Equipment, Dr. Livia Benigni
The market is full of different radiography systems and ultrasound machines. This lecture will help the practitioner choose radiology and ultrasound
equipment that are appropriate for a feline veterinary practice.
P Understanding the Cat & Feline-friendly Handling: Part 2, Dr. Ilona Rodan
See Part 1 Abstract Above
10:45 – 11:35 am C Managing the Feline Cancer Patient: Part 1, Dr. Erika Krick
Unique aspects of diagnosing and treating cats with cancer will be discussed. Case examples will be presented to illustrate general concepts about
feline oncology and the specific challenges that arise when treating cats with cancer. Particular attention will be paid to the value of communicating
effectively with owners of cancer patients and supportive care options for these patients.
P Kitties in Crisis: Emergency Care for Cats, Ms. Erica Mattox
Care of felines presenting in emergent situations can be particularly challenging. This presentation provides an overview of some of the various
disease processes which can result in the need for felines to receive emergent care. This will include discussion regarding the clinical signs of these
disease processes including shock.
11:40 – 12:30 pm C Managing the Feline Cancer Patient: Part 2, Dr. Erika Krick
P How to Survive the Hospitalized Cat: Feline Patient Care, Ms. Erica Mattox
Stabilization and treatment for feline patients often requires hospitalized care for an extended period of time. Care of hospitalized feline patients
should promote wellness and recovery from illness or injury and address the patient’s physical and emotional wellbeing. This presentation will
discuss the challenges of the hospitalized feline and tips to help veterinary technicians be successful in providing patients with excellent care.
12:45 – 1:45 pm Lunch & Learn: Update on Feline Anaplasmosis, Dr. Michael Lappin
In the lecture, Dr. Lappin will talk about clinical features, diagnostics, and management of feline anaplasmosis in cats that may be common in regions
with Ixodes spp. of ticks.
12:50 – 1:20 pm ABVP: Is It For Me?
The American Board of Veterinary Practitioners will offer a short informational presentation exploring the benefits of getting Board-Certified in Feline
Practice. Find out why the 90 Board Certified Feline Practitioners on Planet Earth stand out from the rest!
1:30 – 5:30 pm L Feline Dental Radiology Masterclass and Hands-on Lab #2, Dr. Brook Niemiec
See Lab #1 Abstract Above
2:00 – 2:50 pm A Oral Tumors in Cats: Hope for the Future, Dr. Annette Smith
Squamous cell carcinomas are the most common tumors in cats, with few treatment options. Identification of targets in these tumors may provide
new directions for more successful therapy. Diagnosis of these tumors, a plan for reasonable diagnostics in staging, current treatment options and
success rates, and the potential for future treatments will be presented.
B Feline Lymphoma, Dr. Erika Krick
What’s new, lymphoma cats? This talk will focus on new information about diagnosis, prognostic factors, and treatment recommendations for feline
lymphoma. Histopathological classification, immunohistochemistry, and PARR testing for feline lymphoma as well as an update on small cell
lymphoma will be discussed. Treatment approaches such as vinblastine chemotherapy and radiation therapy and the role of body weight, body
condition score, and supportive care in the treatment of cats with lymphoma will be discussed.
P Kitties vs. Kidneys: Feline Kidney Disease, Ms. Erica Mattox
Renal disease is a commonly encountered presentation to the veterinary hospital for feline patients. This session will discuss the normal anatomy
and physiology of the feline renal system and the pathophysiology. The technician’s role in treatment will also be addressed.
2:55 – 3:45 pm A Management of Feline Large-cell Lymphoma Updates, Dr. Annette Smith
Recent papers provide evidence that chemotherapy protocols for cats with large-cell lymphoma should be re-examined. The various approaches to
treatment through a review of the literature will be presented. The latest protocols for cats will be recommended.
B Neoplastic Effusions, Dr. Erika Krick
What did I just pull out of this cat's chest? Common causes of neoplastic effusions, such as lymphoma and carcinomatosis, from diagnosis to
treatment and prognosis will be discussed. Case examples will be used to highlight specific diagnostic techniques and treatment options.
P Trouble in the Urethra: Feline Lower Urinary Tract Disease, Ms. Erica Mattox
Feline lower urinary tract disease (FLUTD) describes a collection of conditions that can affect the bladder and urethra of cats. This presentation will
discuss the normal anatomy and physiology of the feline urinary tract and the pathophysiology associated with FLUTD. The technician’s role in
treatment will also be addressed.
3:50 – 4:45 pm Cat Friendly Practice Forum
This will be an informal open discussion about tips and creative solutions for implementing the AAFP's Cat Friendly Practice checklist items. Please
bring specific questions you’d like to ask or advice you would like to share.

K E Y: A TRACK A
SUNDAY, OCTOBER 4, 2015

8:30 – 9:20 am A Secrets to Improve Quality-of-Life for Cats with Cancer, Dr. Greg Ogilvie
Throw away the dog books when dealing with the unique needs, physiology, behavior, and response to therapy of cats with cancer. Come join this
dynamic, interactive lecture where we will discuss the latest advice on effective, practical ways to improve quality-of-life for the cat with cancer by
relieving pain, nausea, diarrhea, anorexia, etc. with compassionate care. We will also focus on supporting the families that go through this difficult
fight. This lecture applies to all patients...not just cats with cancer!
B Chemotherapy Drugs, Dr. Erika Krick
From the tried and true classics, to the modern era, indications, and side effects of chemotherapy drugs will be presented. Evidence (or lack thereof)
for using certain chemotherapy drugs for specific cancers and expectations of response will be discussed. Special focus will be given to the use of
tyrosine kinase inhibitors in cats.
9:25 – 10:15 am A Care Beyond a Cure: Diagnostic Secrets & the Cancer Patient, Dr. Greg Ogilvie
This fun, interactive case-based presentation will explore the latest findings on recent advances on the most effective, practical, and important
staging, grading, and diagnostic techniques in cats. Along the way, we will explore new knowledge about unique cat cancers and methods to enhance
quality-of-life: Cats are NOT small dogs! Included will be important prognostic indicators for predicting response to therapy and survival. We are in
the midst of a brave new world of molecular diagnostics including flow cytometry, PARR, PCR, PCNA, AgNOR, alpha-1-AG and biopsies with Temno
instruments, Jamshidi needles, etc.
B Less Common Cat Cancers, Dr. Erika Krick
This talk will focus on cats with cancer that do not have lymphoma. Some less common cancers in cats include mast cell tumors, injection site
sarcomas, mammary carcinoma, and other solid tumors. Tips and techniques for diagnosis and staging will be presented along with an evidence-based
analysis of treatment recommendations and controversies.
10:45 – 11:35 am A Injection Site Associated & other Soft Tissue Sarcomas: New Advances for 2015, Dr. Greg Ogilvie
Soft tissue sarcomas are very common with a very high recurrence rate. The reality is that most are curable if treated appropriately. Join this
practical, interactive presentation as we discuss the biggest problem our profession has to face: inducing cancer with a preventive vaccine. This hits
at the very center of the bond centered practice as we have all heard and been taught "above all, do no harm." Come hear how we can turn this
problem into a great opportunity to develop a practice focused on the bond.
B Top oncology Mistakes & how to Avoid Them: Part 1, Dr. Sue Ettinger
We will discuss the Do’s and Don’ts for you and your cancer patients with an emphasis on the feline patient. This will cover the most common
oncology mistakes - including diagnostics, surgery, chemotherapy, and radiation. Dr. Ettinger will give practical tips to help you avoid them in your
practice. Cancer is not a death sentence, so please join me and learn how we can help our patients live longer and live well with cancer.
11:40 – 12:30 pm A 10 Best kept Secrets for Treating Cats with Cancer, Dr. Greg Ogilvie
This fun, case-based, video-enhanced, interactive presentation will capitalize on the experience of the audience and speaker to learn new, practical
techniques for treating cats with cancer and associated disorders and diseases. What are the deep dark secrets of managing cats with respiratory,
gastrointestinal, cardiovascular, and hematopoietic malignancies? Come and find out! This lecture will reveal many secrets described in the book,
Feline Oncology: A Comprehensive Guide to Compassionate Care for Cats with Cancer.
B Top oncology Mistakes & how to Avoid Them: Part 2, Dr. Sue Ettinger
12:40 – 1:40 pm Lunch & Learn: Diarrhea Dilemma: What We Think We Know About Treatment of IBD, Dr. Susan Little
IBD is an immunologically mediated chronic enteropathy. Given that we do not know the causes of this heterogenous group of disorders, treatment
recommendations are empiric. Treatment decisions are complicated by the fact that we lack randomized controlled drug trials to evaluate the efficacy
of therapies and clinical data is sparse for alternate therapies. This presentation will review the current state of knowledge about treatment options
for feline IBD.
1:45 – 2:35 pm A kitty oncologic Emergencies: hELP!!!, Dr. Greg Ogilvie
Cancer is one of the most dynamic areas of veterinary medicine including in the critical care setting. This multi-media presentation will explore the
most important and common emergencies, and share how even the worst cases can be saved with fast action and new treatments! Remember, we
not only care for our kitties, but the frightened and bewildered families who bring their feline friends to us for care in crisis.
B See Something, Do Something. Why Wait? Aspirate,TM, Dr. Sue Ettinger
In veterinary medicine, most skin and subcutaneous tumors can be cured with surgery alone if diagnosed early when tumors are small. “See
Something, Do Something” (SSDS) is Dr. Ettinger’s cancer awareness program for lumps and bumps in dogs and cats that is launching in 2015. SSDS
provides pet owners and veterinarians guidelines for evaluating superficial masses in dogs and cats. These guidelines will increase client awareness,
promote early cancer detection and diagnosis, as well as early surgical intervention. Early detection saves lives.
2:40 – 3:30 pm A The Secret Weapon: Polyunsaturated Fatty Acids & Cancer: Advances for 2015, Dr. Greg Ogilvie
Our clients are reading and hearing about the new discoveries on how nutrition can be used to fight cancer and improve quality-of-life in people and in
cats. They are also demanding the very best care for their cat with cancer and that includes nutrition. This interactive presentation will explore the most
recent discoveries on how nutrition can be used in combination with other therapies to improve quality and length of life in the kitty cancer patient.
B Practical Take-home Tips for Managing Feline Cancer Patients in Your Practice, Dr. Sue Ettinger
Whether you refer your feline cancer cases to a specialist or manage them in your practice, Dr. Ettinger will discuss her guidelines and tips for
chemotherapy patients including: interpreting blood work before chemotherapy and the nadir CBC after chemotherapy, when to use antibiotics and
which ones; how to manage chemotherapy-related side effects and tips to minimize them in the first place; appropriate monitoring and testing during
treatment; tips for patients that choose palliative care only (like steroids for lymphoma); and new options for patients with advanced metastatic disease.

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• Journal of Feline Medicine and Surgery (JFMS) • The Scratching Post

Members of the AAFP receive a monthly subscription to the This bi-monthly e-newsletter is designed to keep members
JFMS, which is a significant value and membership benefit abreast of the latest association news and events in addition
(12 issues of JFMS is valued at $352). It also includes an to valuable feline scientific content produced by members.
easy-to-use online platform in the Member’s Only Center
where you can access current and past issues of the JFMS, • Webinar Portal
download full PDF issues, and search for specific articles The AAFP provides its members with free access to a
or key words. Webinar Portal which provides complimentary feline-specific
continuing education. The Webinar Portal is accessed
• JFMS Open Reports through the Member Center.
JFMS Open Reports, the new sister title to the JFMS, is an
open access journal where all articles are freely accessible to • AAFP Print Membership Directory
any reader online. JFMS Open Reports publishes high quality The printed membership directory is made available to all
case reports, short case studies and short communications members of the AAFP and allows for convenient access to
on all aspects of feline medicine and surgery. AAFP members colleague information.
receive a reduced articled processing charge if you submit
an article and it’s approved for publication. • VIN Member Discount and AAFP Rounds on VIN
All active AAFP members receive a 10% discount on VIN
• Cat Friendly Practice (CFP) Program membership! Our collaboration with VIN also enables us
The AAFP’s Cat Friendly Practice Program was created to to provide our members with free access to AAFP rounds on
equip veterinary practices with the tools, resources, and VIN. The rounds allow members to have access to additional
information to elevate the standard of care for cats. The complementary feline focused education.
program aims to help increase feline visits by providing
practitioners with the guidelines and resources to become a • Client Brochures
CFP. It also concentrates on decreasing the stress associated The AAFP has a collection of printed client brochures
with the visit and promoting routine veterinary visits. Access available to help educate your clients on important feline
to the program is free with AAFP membership. For more health topics such as Feline House-Soiling, Environmental
information visit: www.catvets.com/cfp Needs for Your Cat, Vaccinations for Your Cat, Getting Your
Cat to the Veterinarian, and Nursing Care for Your Cat. These
• Find a Feline Practitioner (public online search) publications are available for members to print and distribute
Members of the AAFP can choose to be included in our - www.catvets.com/guidelines/client-brochures.
online, public facing member directory called ‘Find
Veterinarians and Practices.’ The search assists cat owners • Past Conference Proceedings
in finding a local veterinarian committed to feline healthcare, Members can access archives of all past conference pro-
as well as allows other colleagues to search for you for ceedings notes through the Member Center on our website.
referrals or your contact information.
• Member Center
• Practice Guidelines and Position Statements All members of the AAFP have access to the Online Member
The AAFP provides advanced member-only previews of all Center, an exclusive area on the AAFP website dedicated
Practice Guidelines and Position Statements released by the to housing member-only exclusive benefits. Here members
AAFP. These resources serve as the foundation for practice have easy access to the online JFMS, past conference
excellence and the AAFP’s high standards of feline care. proceedings, Scratching Post e-newsletters, classified ad
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www.catvets.com
www.catvets.com/education/October
October
1 –14,– 4,
2015
2015American
AmericanAssociation
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of of
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Feline Practitioners 2121
Practitioners
Make a difference in feline medicine.
Become a Cat Friendly Practice!
The American Association of Feline

Practitioners’ Cat Friendly Practice
Program provides the tools for veterinary
professionals to integrate a feline
perspective and embrace the standards
needed to elevate care for cats. It equips
practices with the tools, resources, and
information to improve the treatment,
handling, and overall healthcare of cats.
The CFP program also focuses on reducing
the stress of the veterinary visit for
veterinary staff, cats, and their owners.
Interested in the Cat Friendly Practice Program?
As of July 17, 2015, 897 practices have Come to our open forum Saturday, October 3, 3:50-4:45 pm.
been designated as CFPs. Please bring specific questions you’d like to ask or advice you’d
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2015
3 WORLD FELINE
rd
VETERINARY
CONFERENCE THURSDAY, OCTOBER 1, 2015 5 Additional CE Hours
Pre-conference Day Sessions
PRE-CONFERENCE SESSIONS
Sponsored by
Food for Thought Luncheon in Grand Hall D
Pre-conference registration required
Chronic Kidney Disease: Making the Most of Early Diagnosis 11:15 – 12:45 pm
Dr. S. Dru Forrester and Dr. Jane Robertson
Sponsored by
ABVP/AAFP Seminar & Social in Grand Hall C 1:00 – 5:30 pm
End of Life Issues in Feline Medicine 1:00 – 2:00 pm

Dr. William Folger
Death & Dying: Feline Euthanasia in the Clinical Setting 2:00 – 3:00 pm
Dr. Elizabeth Colleran
Sponsored by
Seminar & Social Refreshment Break 3:00 – 3:30 pm

Dr. Margie Scherk 3:30 – 4:30 pm
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Dr. Susan Little
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Track Descriptions
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www.catvets.com/education/ October 1 – 4, 2015 American Association of Feline Practitioners

American Association of Feline Practitioners
ABVP Seminar & Social
2015 Conference ● October 1 - 4, 2015 ● San Diego, CA
Chronic Kidney Disease: Making the Most of Early Diagnosis

S. Dru Forrester, DVM, MS, DACVIM & Jane Robertson, DVM, DACVIM
Introduction
Chronic kidney disease (CKD) is common in cats and its occurrence increases with age. Recent availability
of a new diagnostic test (symmetrical dimethylarginine or SDMA) helps identify CKD in the early stages when
therapeutic intervention could have the greatest impact on outcome. Recommended management options should be
based on IRIS staging of CKD. While there are many therapeutic options for cats with CKD, nutritional management
is the only one shown to improve survival and quality of life in a randomized, controlled clinical study. There are
some simple tips that can greatly enhance success when transitioning to new foods in cats with CKD.
Clinical Presentation
In cats, clinical signs of CKD may not be present in early stages. Cats typically maintain their urine
concentrating in early stages of CKD; therefore, polyuria (PU) and polydipsia (PD) are often not recognized until later
stages, and cat owners are more likely to recognize PD than PU. As the disease progresses cats can present with
nonspecific signs including poor body condition, weight loss, decreased appetite, lethargy and dehydration.
Intermittent vomiting secondary to uremic gastric ulceration may occur. A cat may be asymptomatic until dehydration
(potentially due to an unrelated cause) leads to decompensation and an acute presentation.
Physical examination findings in cats with CKD will vary depending on the stage of disease. Early in the
disease (IRIS stages 1 and 2), physical examination may be within normal limits. Palpable renal abnormalities may
be detected: small, firm and irregular kidney[s], one big kidney and one little kidney, or enlarged kidneys (polycystic
kidney disease, lymphoma). As CKD progresses to IRIS stages 3 and 4, clinical signs will become more apparent
and reflect the chronic nature of the disease. General physical examination findings include poor body condition,
unkempt hair coat, dehydration and palpable kidney abnormalities. Oral examination may reveal pale mucous
membranes, ulcers and/or uremic breath. Secondary systemic hypertension may cause retinal hemorrhages, arterial
tortuosity or detached retinas presenting as acute blindness.
Diagnosis
A diagnosis of CKD is typically straight forward once the disease is in its later stages and there is clinical
suspicion based on history and physical examination findings, azotemia evident on biochemical profile and loss of
urine concentrating ability. However, recognition of CKD can be challenging early in the course of disease because
clinical signs may be absent, mild or attributed to another concurrent condition and azotemia does not typically
develop until up to 75% loss of nephron function. To add to the confusion, cats often retain some urine concentrating
ability until later in the disease process.
Blood urea nitrogen (BUN) and serum creatinine concentrations are routinely used biochemical tests to help
diagnose kidney disease. BUN can be influenced by several extra-renal factors including dehydration, dietary protein
content, gastrointestinal bleeding and hepatic insufficiency. Creatinine is a breakdown product of muscle and is a
better indicator of glomerular filtration rate (GFR) than BUN; it can be influenced by a reduction in muscle mass,
which is not uncommon in older cats with CKD. When non-renal variables have been eliminated, an increase in BUN
and/or creatinine above normal indicates that up to 75% of nephrons are not functioning. Clearly, it would be
advantageous to identify kidney disease earlier. Performing creatinine measurements routinely during wellness visits
can establish a normal baseline for individual cats. An upward trend in creatinine, while it is still within the reference
interval, can be helpful to identify CKD earlier, prior to creatinine increasing above the reference interval.
Other common abnormal findings on the CBC and chemistry panel include a non-regenerative anemia,
hyperphosphatemia, hypercalcemia or hypocalcemia, hypokalemia and metabolic acidosis. Common findings on a
urinalysis include inappropriate urine specific gravity (<1.035), casts, evidence of a urinary tract infection and
proteinuria. A urine protein:creatinine ratio (UPC) is recommended to determine the degree of proteinuria.
Introducing a New Kidney Test: SDMA

Symmetrical dimethylarginine (SDMA) is a new kidney function test that was introduced this summer. SDMA
is a methylated form of the amino acid arginine, which is released into the circulation during protein degradation and
is excreted by the kidneys. Because SDMA is eliminated by renal filtration, it has been shown to correlate very well
1
with GFR in cats. SDMA increases earlier than creatinine in patients with CKD. On average, SDMA increases with
40% loss of kidney function and as early as with 25% kidney functional loss. However, creatinine does not increase
until up to 75% of kidney function is lost. Research has shown that SDMA can identify CKD an average of 17 months
2
sooner in cats. In addition, SDMA is not impacted by muscle mass, thereby providing practitioners a better tool for
3
diagnosing and monitoring CKD in thin geriatric cats and cats with other conditions that cause muscle wasting.
25
Early diagnosis provides the opportunity to investigate for an underlying cause, especially more treatable
conditions such as pyelonephritis and obstruction, and to IRIS substage the CKD for proteinuria and hypertension.
Identified causes, hypertension and proteinuria can be treated or managed. Practices to avoid further kidney damage
can be implemented like taking precautions with prescribed drugs and when anesthetizing the cat. The cat can be
monitored more closely to determine and recognize progression of the CKD.
Staging of Chronic Kidney Disease

Historically, CKD has been classified as mild, moderate, or severe, based on laboratory findings and clinical
signs. A less arbitrary classification system has been developed by the International Renal Interest Society or IRIS
(www.iris-kidney.com). CKD has to be first diagnosed, and then IRIS staging can be applied. IRIS staging is based
initially on fasting plasma creatinine, assessed on at least two occasions in the stable patient (Table 1). The patient
is then sub-staged based on proteinuria and blood pressure (Tables 2 and 3).
4
Table 1: IRIS Staging System for Chronic Kidney Disease in Cats
Stage Renal Azotemia Creatinine Comments

1 Non-azotemic <1.6 mg/dl Confirmed kidney disease present:
• inadequate urine concentrating ability
<140 µmol/L
• decreased GFR confirmed by other testing
• abnormal renal palpation, imaging or biopsy
• proteinuria of renal origin
2 Mild 1.6-2.8 mg/dl Clinical signs usually mild or absent
140-249 µmol/L
3 Moderate 2.9-5.0 mg/dl Many systemic clinical signs may be present
250-439 µmol/L
4 Severe >5.0 mg/dl Many systemic clinical signs usually present
>440 µmol/L
Table 2: IRIS Substaging by Proteinuia in Cats with Chronic Kidney Disease
Urine Protein:Creatinine Ratio (UPC) Substage

<0.2 Non-proteinuric (NP)
0.2-0.4 Borderline proteinuric (BP)
>0.4 Proteinuric (P)
Table 3: IRIS Substaging by Blood Pressue in Cats with Chronic Kidney Disease
Systolic BP in mm Hg Diastolic BP in mm Hg Substage*

<150 <95 Minimal risk (N)
150-159 95-99 Low risk (L)
160-179 100-119 Moderate risk (M)
>180 >120 High risk (H)
*Risk = likelihood that high pressure will further damage the kidney and other end organs.
Prognosis
Several studies have evaluated IRIS stage of CKD based on serum creatinine at the time of diagnosis and
5,6
found that it is strongly predictive of survival in cats with naturally occurring CKD. Results from one study are
5
summarized below (Table 4). Despite the fact that the level of proteinuria is relatively low in cats with CKD, the
degree of proteinuria has also been independently related to survival in cats with renal failure. One study found that
death or euthanasia was 2.9 times more likely in cats with UPC of 0.2-0.4 and 4 times more likely in cats with UPC
6
>0.4 compared to cats with a UPC of <0.2.
26
Table 4: Survival time by IRIS Stage
IRIS Stage 2b* 3 4

Median survival (days) 1,151 778 103
Range (days) 2 – 3,107 22 – 2,100 1 – 1,920
*2b = Creatinine of 2.3-2.8 mg/dl (203-249 µmol/L)
Treatment Recommendations
An individualized therapeutic approach should be designed based on the IRIS stage of disease (Table 5)
and the individual cat’s needs. Historically, treatment for CKD has been initiated relatively late in the disease process
because of the difficulty of early diagnosis. Using SDMA will help clinicians diagnose CKD in IRIS Stage 1 or early
IRIS Stage 2, which should prompt investigation for an underlying cause with potential for specific treatment. It will
allow for sub-staging CKD so that proteinuria and hypertension can be detected and managed earlier in the disease
process. Early management of CKD may slow progression of the disease. Closer monitoring will help identify
progression and when additional therapies should be initiated.
4
Table 5: IRIS Treatment Recommendations for Cats with Chronic Kidney Disease
Stage Recommended Treatment

• Closely monitor for progression if UPC = 0.4 to 1
1 • ACE inhibitor and dietary protein reduction if UPC > 1
• Renal diet (± phosphate binder)
2 • Closely monitor for progression if UPC = 0.2 to 0.4
• ACE inhibitor if UPC > 0.4
Evidence Supporting Treatments for Chronic Kidney Disease

While many treatment options exist for feline patients with CKD, nutritional management with a therapeutic
renal food is supported by the highest level of evidence for IRIS Stages 2-4 and is recommended as the standard of
4,7-10
care. Results of an uncontrolled, non-randomized, non-blinded clinical study of 50 cats revealed that cats fed a
renal food (Waltham Veterinary Diet, Whiskas Low Phosphorus Low Protein) had a significantly longer median
7
survival time (633 days) compared with cats that continued eating their regular food (264 days). In a randomized,
double-blinded clinical study comparing effects of feeding a therapeutic renal food (Hill’s Prescription Diet k/d Feline)
with a control food, significantly more cats (26%) fed the control food had uremic episodes compared with the renal
9
food (0%). There was also a significant reduction in renal-related mortality in cats fed the renal food; none of the
cats in the renal food group died from renal causes, whereas, 22% of cats in the control food group died.
Features of Therapeutic Renal Foods

Compared with typical feline maintenance foods, therapeutic renal foods contain a “package” of nutrients that
are believed to be helpful for feline patients with CKD (Table 6). These include controlled amounts of high
quality/highly digestible protein, phosphorus and sodium, increased buffering capacity to help combat metabolic
acidosis, added potassium to manage hypokalemia, and increased amounts of omega-3 fatty acids. Antioxidants
such as vitamins E and C and β-carotene are added to minimize oxidative stress, which has been documented in
11,12
cats with CKD and may contribute to disease progression. When communicating with pet parents, it’s helpful to
explain that foods designed for CKD include several features that distinguish them from typical cat foods versus
referring to them only as low-protein foods. While renal foods contain less protein compared with adult maintenance
pet foods, these proteins are of high quality (providing essential amino acids only) and are highly digestible. Lower-
quality protein sources typically contain non-essential amino acids, which are not required by the patient but may be
catabolized to urea and other nitrogen-containing wastes that normally are eliminated by the kidneys and may
contribute to clinical signs in later stages of CKD.
27
Table 6: Nutrient Content (% Dry Matter Basis) of Renal Foods Versus Other Selected Feline Foods
Food Phosphorus Protein Sodium

Therapeutic Renal Food* 0.5 28-29 0.2
Feline Maintenance Food* 0.9 to 1 46-48 0.4
Hill’s Prescription Diet g/d Feline (early renal) 0.52-0.57 33-34 0.3
Hill’s Science Diet Age-Defying (dry) 0.6 35 0.3
Hill’s Ideal Balance Grain-Free Gourmet Tuna Recipe (can) 0.6 38 0.5
Hill’s Prescription Diet j/d Feline 0.7-0.8 37-38 0.34-0.41
Hill’s Prescription Diet m/d Feline** 0.7-0.8 51-53 0.36-0.41
Purina Pro Plan FINESSE Adult Chicken Tuna & Wild Rice Entree 0.72 47 1.2
Purina Fancy Feast Delights with Cheddar Grilled Turkey 1.02 56 1.72
Purina Cat Chow Complete 1.3 36 0.51
Purina DM Dietetic Management Feline Formula** 1.27-1.4 53-58 0.46-0.6
Purina Fancy Feast Classic Ocean Whitefish & Tuna Feast 2.1 60 0.87
*Foods used in a randomized, controlled clinical study showing improved survival and quality of life in cats fed a therapeutic renal
9
food versus a maintenance food
**Contraindicated/not recommended for cats with CKD/renal failure according to manufacturer’s product guide
Dietary Protein, Phosphorus, and Cats with CKD

Sarcopenia (age-related loss of lean body mass) and cachexia (loss of lean body mass due to systemic
disease) often are concerns in older cats, particularly those with CKD. Caloric intake is essential for cats with
cachexia because protein will be metabolized to provide a source of calories if the daily energy needs are
continuously unmet. When recommending foods for cats with CKD, it’s important to ensure their dietary protein
needs are met – this involves more than considering protein quantity, however. Therapeutic renal foods contain more
than adequate amounts of dietary protein to meet the needs of cats with CKD that are consuming adequate calories.
It’s important to also consider protein quality (amino acid content) and digestibility – renal foods contain high quality
protein (essential amino acids) that is highly digestible. For cats that need additional protein, consult with the pet food
manufacturer to identify foods that contain more protein but are still relatively lower in phosphorus and ideally contain
the other beneficial features of a therapeutic renal food.
Regardless of opinions on the ideal amount of dietary protein, it is widely accepted that restricting dietary
4,10,13,14
phosphorous intake is beneficial in cats with CKD. Dietary phosphorus amounts that have been associated
with beneficial effects in cats with CKD range from 0.27 to 0.5% (dry matter basis) whereas amounts ranging from
0.9 to to 1.9% (dry matter basis) have been associated with negative consequences in cats with CKD, including
decreased survival time, decreased quality of life, more uremic episodes, and renal histologic changes including
7,9,14
mineralization, fibrosis, and cellular infiltration. Some have advocated concurrent feeding of higher-protein diets
15
to cats with CKD along with using phosphate binders instead of feeding a therapeutic renal diet. This approach is
not supported by peer-reviewed, published evidence or current guidelines that have been established/accepted by
4,10,16,17
the veterinary profession. It is critical to understand that most high-protein foods contain dietary phosphorus
amounts that are excessive for cats with CKD (often 1-2% on a dry matter basis) (Table 6). For cats with CKD, the
currently accepted standard of care is to recommend a renal diet first, and use dietary phosphate binders when
nutritional management alone is not able to maintain serum phosphorus concentrations within the recommended
4,10
range.
Tips for Successful Transition to a Renal Food

The myth that cats won’t eat therapeutic renal foods has unfortunately persisted despite commercially
available options that are readily accepted by feline patients with CKD. In a study published in 2014, 92% of cats with
IRIS Stage 2 or 3 CKD accepted the therapeutic renal food when it was offered – in some cats, acceptance may
18
have been facilitated by a 14-day transition period. In a prospective, double-blinded study of 128 client-owned cats
(33 normal and 95 with varying stages of CKD), 94% of cats successfully transitioned (over a 7-day period) from their
regular food to a therapeutic renal food (Prescription Diet k/d Feline) and 88% of owners believed their cat liked the
19
renal food. And 91% of cats with CKD continued eating a therapeutic renal food during a 2-year clinical study,
9
comparable to the control group of cats where 87% continued eating a maintenance food.
28
While today’s therapeutic renal foods taste great and are available in a variety of forms and flavors, there are
cats that are reluctant to eat any new food. The following 3 guidelines may help ease the transition to a new food,
especially for cats with CKD.
1. Education – It’s important to educate pet owners about effectiveness of nutritional management for prolonging
survival time and improving quality of life in patients with CKD. There are many treatments that are
recommended and used for patients with CKD; however, nutritional management is the only treatment that has
been shown to significantly prolong survival time in cats with CKD. Therefore, it is extremely important to make
the effort to transition patients to a therapeutic renal food. In order for treatment to succeed, owners must commit
their time and money, which is more likely to occur if they understand the benefits of their efforts.
2. Ambience - Avoid offering therapeutic renal foods in stressful environments (sick and/or hospitalized, during
force-feeding); a food aversion may develop causing decreased acceptance of the food when the patient is
feeling better. Stated another way - while hospitalized, do not feed cats the food you want them to eat for the
rest of their lives. In this situation, one option would be to initially feed a maintenance food that avoids excessive
protein, phosphorus, and sodium and then begin gradual transition to a therapeutic renal food when the patient is
at home and feeling better.
3. Transition – The single most important thing you can do to increase patient acceptance of a therapeutic renal
food is gradually transition to the new food. The transition period should be a minimum of 7 days; however,
some cats need a transition of 3 to 4 weeks or longer. Chronic kidney disease doesn’t occur overnight and it’s
acceptable to take the necessary time to gradually transition to a renal food. It is critical to discuss the need for
this transition with pet owners, otherwise, they are likely to take the new food home, and switch “cold turkey” from
the old food to the new food at the next meal. The outcome of this scenario is very predictable – most cats will
refuse to eat the new food, which results in an unhappy owner and a patient with CKD that will likely never
receive the maximal benefits of nutritional management. For “fussy” eaters, one option for transitioning is to mix
the old and new food, gradually adding more of the new food over time. Another approach is to provide both
foods (old and new) in side-by-side food dishes. This technique assists with gradual transition and also allows
cats to express their preferences versus being forced to eat the new food suddenly. If transitioning from dry to
canned food, use a flat dish/saucer instead of a bowl. This avoids rubbing of the cat’s whiskers on the food dish,
which could affect acceptance of new food.
Managing Cats with Early (IRIS Stage 1) Kidney Disease

20
Early diagnosis offers some potential advantages for treatment outcomes in patients with CKD. Because
there is more residual renal function remaining, early intervention has a much greater impact on length of survival.
And most therapeutic strategies are likely to be more effective when they are applied early versus later in the course
of disease. It seems reasonable to recommend a therapeutic renal food (or a food with a “renal-friendly” nutrient
profile) because this is the only therapeutic intervention that has been shown to significantly improve survival time in
cats with IRIS Stages 2&3 CKD. Some have recommended introducing a renal diet earlier in the course of CKD
(when the cat is clinically well) because of the belief/clinical experience that dietary acceptance may be higher than
16
waiting until disease has progressed. Another approach is to carefully monitor and implement nutritional changes
as soon as there is any evidence of progression (e.g., increasing SDMA, UPC, serial creatinine values) in cats with
Stage I CKD.
Summary
SDMA is a new kidney function test that will enable veterinarians to detect CKD earlier in clinically healthy
cats during routine preventive care and pre-anesthetic testing. It will also provide practitioners a better tool to
diagnose CKD in cats with nonspecific clinical signs such as decreased appetite and weight loss. Early diagnosis will
provide the opportunity to identify an underlying cause and for earlier management of CKD with implementing diets
and medications at the earliest appropriate time, to improve quality of life and slow disease progression. Based on
published evidence, feeding a therapeutic renal food is the single-most effective treatment for improving survival and
quality of life in cats with CKD. Most cats (> 90%) will successfully transition to eating a renal diet – for more finicky
patients, simple guidelines (Education, Ambience, Transition) will increase the likelihood of a successful outcome.
References
1. Braff J, Obare E, Yerramilli M, et al. Relationship between serum symmetric dimethylarginine concentration
and glomerular filtration rate in cats. J Vet Intern Med 2014;28:1699-1701.
2. Hall JA, Yerramilli M, Obare E, et al. Comparison of serum concentrations of symmetric dimethylarginine and
creatinine as kidney function biomarkers in cats with chronic kidney disease. J Vet Intern Med 2014;28:1676-
1683.
3. Hall JA, Yerramilli M, Obare E, et al. Comparison of serum concentrations of symmetric dimethylarginine and
creatinine as kidney function biomarkers in healthy geriatric cats fed reduced protein foods enriched with fish
oil, L-carnitine, and medium-chain triglycerides. Vet J 2014;202:588-596.
4. IRIS. www.iris-kidney.com: International Renal Interest Society, 2013 (accessed July 2015)
29
5. Boyd LM, Langston C, Thompson K, et al. Survival in cats with naturally occurring chronic kidney disease
(2000-2002). J Vet Intern Med 2008;22:1111-1117.
6. Syme HM, Markwell PJ, Pfeiffer D, et al. Survival of cats with naturally occurring chronic renal failure is
related to severity of proteinuria. J Vet Intern Med 2006;20:528-535.
7. Elliott J, Rawlings JM, Markwell PJ, et al. Survival of cats with naturally occurring chronic renal failure: effect
of dietary management. J Small Anim Pract 2000;41:235-242.
8. Harte JG, Markwell PJ, Moraillon RM, et al. Dietary management of naturally occurring chronic renal failure
in cats. J Nutr 1994;124:2660S-2662S.
9. Ross S, Osborne C, Kirk C, et al. Clinical evaluation of dietary modification for treatment of spontaneous
chronic kidney disease in cats. J Am Vet Med Assoc 2006;229:949-957.
10. Polzin DJ. Evidence-based step-wise approach to managing chronic kidney disease in dogs and cats. J Vet
Emerg Crit Care 2013;23:205-215.
11. Brown SA. Oxidative stress & chronic kidney disease. Vet Clin North Am Small Anim Pract 2008;38:157-166.
12. Yu S, Paetau-Robinson I. Dietary supplements of vitamins E and C and beta-carotene reduce oxidative
stress in cats with renal insufficiency. Vet Res Commun 2006;30:403-413.
13. Barber PJ, Rawlings JM, Markwell PJ, et al. Effect of dietary phosphate restriction on renal secondary
hyperparathyroidism in the cat. J Small Anim Pract 1999;40:62-70.
14. Ross LA, Finco DR, Crowell WA. Effect of dietary phosphorus restriction on the kidneys of cats with reduced
renal mass. Am J Vet Res 1982;43:1023-1026.
15. Norsworthy G, Lavallee J. Chronic renal disease: new directions in therapy, Parts 1 and 2. Proc Western Vet
Conf 2015.
16. Korman RM, White JD. Feline CKD: Current therapies - what is achievable? J Feline Med Surg 2013;15
Suppl 1:29-44.
17. Brown SA, Rickertsen M, Sheldon S. Effects of an intestinal phosphorus binder on serum phosphorus and
parathyroid hormone concentration in cats with reduced renal function. Intern J Appl Res Vet Med
2008;6:155-160.
18. Hanzlicek AS, Roof CJ, Sanderson MW, et al. The effect of Chinese rhubarb, Rheum officinale, with and
without benazepril on the progression of naturally occurring chronic kidney disease in cats. J Vet Intern Med
2014;28:1221-1228.
19. Fritsch D, Jewell D. Acceptance and effects of a therapeutic renal food in pet cats with chronic kidney
disease. Vet Record Open 2015 (in press).
20. Lees GE. Early diagnosis of renal disease and renal failure. Vet Clin North Am Small Anim Pract
2004;34:867-885.
NOTES
30
End of Life Issues in Feline Medicine

William Folger, DVM, MS, DABVP (Feline)
Introduction
Most veterinarians are good, honest people with a broad sense of decency and respect. Veterinarians are
strongly motivated to help their patients avoid unnecessary suffering. Bottom line- veterinarians want to do the right
thing by their patients.
“What makes veterinary medicine a true profession, as distinguished from a trade or occupation, it its
endorsement of fundamental ethical values and its desire to make goodness of purpose as much a part of its mission
as technical competence.”- Tannenbaum
There has been a metamorphosis of the importance of the pet in the family structure in the last 50 years.
“Just a few decades ago, it was very common for a veterinarian to routinely recommend euthanasia for many
chronic, debilitating and terminal illnesses such as feline leukemia virus infection, chronic renal disease, diabetes
mellitus and lymphoma. Towards the end of the last century, a growing awareness and appreciation by the general
public of the significant importance of our relationship with our pets was recognized. Veterinarians acknowledge and
honor the human-animal bond.” Folger/Scherk
The Role of Aesculapian Authority and Its proper Use

“Aesculapian authority is the uniquely powerful authority vested in those society perceives as healers,
historically traceable to the time when medicine was inseparable from magic and religion.” -Rollin. Aesculapian
authority evolves as a direct culmination of three types of authority:
1. Expert authority: education, training, and experience
2. Moral authority: a moral authority to heal, and relieve suffering and retard death.
3. Charismatic or “God-given” authority- medicine is still related to magic or is incomprehensible to the
scientifically and medically naïve. In this decade it is Dr. Google challenging that authority.
4. Proper invocation of aesculapian authority occurs when the veterinarian treating a companion animal the
owner views as a family member, the veterinarian is obliged to consider the needs of the patient first. This
may invoke all the elements of aesculapian authority: appeal to our education, training, and experience;
appeal to our moral authority; and our being viewed as a healer. Rollin makes this excellent point that
veterinary medicine can require great people skills and more time spent with the owners than the diagnostics
and therapy applied to the pet.
The abuse of aesculapian authority is exemplified by medical doctors or medical nurses extracting sexual
favors from a patient. In veterinary medicine it is more common that revenue enhancement is portrayed as “highest
quality of care.”
The misuse of aesculapian authority is a primary component of moral stress. This is divided into two distinct
situations. First, the client demands euthanasia due to trivial reasons- treatable diseases, moving to another house,
getting new furniture, getting married to someone “allergic” to cats, etc. These situations are commonly referred to as
convenience euthanasia. The second situation is just as troubling: the client refusing to euthanize the patient in spite
of a severe, terminal prognosis indicating a need to end the patient suffering.
“Moral stress is the biggest contributor to compassion fatigue”- Kahler. Veterinarians refusing to perform
euthanasia when they don’t think it was the right thing to do, or performing euthanasia when they wished they could
refuse to. Failure to properly manage moral stress will, after a period of time, lead inevitably to compassion fatigue:
Dissociation, numbness, isolation, hypervigilance, sleep deprivation, irritability, avoidance and/or obsession. –Cohen
Dr. Elizabeth Strand, Director and associate clinical Professor, Veterinary Social Work, University of
Tennessee: “It used to be that, if I’m willing to take care of myself, my mental well-being, I’m going to take a vacation.
But that goes against the incredibly honorable work ethic in veterinarians that I have never observed elsewhere.”
The AAFP position statement on convenience euthanasia: “The AAFP is opposed to convenience
euthanasia. It is not in the best interest of the patient, and it is not in the best interest of the veterinary profession to
perpetuate an image of itself as willing to kill a companion animal ‘on demand’.”
Quality of Life Considerations

The Five Freedoms
1. Freedom from hunger, thirst, and malnutrition
2. Freedom from physical or thermal discomfort
3. Freedom from fear and distress
4. Freedom from pain, injury and disease
31
5. Freedom to express normal patterns of behavior as long as it does not cause injury to them or another
species
Rollin- Make a list of thing the cat enjoys while the cat is healthy and happy. As the cat become debilitated,
the owner can review this list to gauge how the cat is doing.
Scherk- Encourage the owner to imaging what the cat is experiencing using a scale of 1 to 10, 10 being the
best day of their life, 1 being equivalent to suffering and hopelessness. Once a cat’s daily life gets into the 2s and 3s-
it’s time to consider euthanasia as a means to alleviate suffering.
Villalobos (Pawspice) - HHHHHMM: Hurt, hunger, hydration, hygiene, happiness, mobility, more good days
than bad.
In about 80-90% of our patients, end of life issues are historically established and documented. As such, one
of the most important principles with respect to the client: Start the conversation as long in advance as is
possible and appropriate.
In order to trigger this conversation, I frequently makes these short remarks in the record:
Skating on thin ice
Close to the edge
Looking for the Promised Land
And at the end of life:
End of the line
Going to the sweet bye and bye
Time to die
The AAFP Position statement: End of Life Issues in Feline Medicine. JFMS (2010)12, pg. 421-422 and
Editorial Drs. Margie Scherk and William Folger JFMS(2010)12, pg. 365-366
Ethical Considerations
1. The existence and availability of a therapeutic or diagnostic modality is not an ethical argument for its use.
2. It is unethical for the veterinarian to deliberately exploit the bond between patient and client to generate a
financial benefit.
3. It is unethical for the veterinarian to encourage the administration of therapies or diagnostics that benefit the
practitioner at the expense of the patient.
4. Dr. Matt Sturmer DVM, cited by Rollin 2007: “just because we can (do something) doesn’t mean that we
should.”
5. The ability of a client to commit financial resources to treat their pet or demand that such treatment be
provided does not constitute a moral or ethical mandate or contract to provide such a treatment.
6. If the emotional bond between owner and patient is so strong and the situation so confusing that the owner is
unwilling or incapable of critically appreciating the prolonged suffering a patient appears to be experiencing,
or that a treatment modality might produce, it is the moral and ethical responsibility of the veterinarian
to focus the attention of the owner on the patient’s quality of life. In about 90% of our patients, this is
most successfully accomplished by initiating the conversation as long in advance as possible.
Principle in Treatment Considerations

1. The needs of the patient must always come first.
2. Above all, do no harm.
3. The veterinarian is, first and foremost, the patient advocate.
4. It is the veterinarian’s responsibility to provide every opportunity for the patient to enjoy The Five Freedoms
and to alleviate patient suffering.
Maintenance of Quality of Life

1. Pain management: “The outdated theory that pain management should be restricted in order to reduce the
activity of the patient is an incorrect and inappropriate rationalization which needs to be permanently
abandoned in veterinary medicine.”- From Dr. Sheilah Robertson
2. Anti-nausea meds
3. Fluids
4. Exercise
5. Love
Nine Case Examples Presented
32
References
nd
1. Tannenbaum, J. Veterinary Ethics: Animal Welfare, Client Relations, Competition and Collegiality, 2 ed.
Mosby-Year Book Inc. 1995.
2. Folger, W, Addleman, et al. AAFP Position Statement; end of life issues in feline medicine. JFMS (2010)12,
p 421-422.
3. Folger, W and Scherk, M: Editorial- The veterinarian’s responsibilities at the end of a cat’s life. JFMS
(2010)12 p 365-366.
4. Rollin, BE, The use and abuse of aesculapian authority in veterinary medicine. JAVMA Vol 220(8) p 1144-
1149, 2002.
5. Kahler, SC, Moral stress the top trigger in veterinarian’s compassion fatigue. JAVMA Vol 246(1) p 16-18,
2015.
6. Cohen, SP, Compassion fatigue and the veterinary health team. Vet Clin Small Anim 37 (2007) p 123-134.
7. Scherk, M and Rollin, BE, Palliative medicine, quality of life, and euthanasia decisions. In Little, S. The Cat:
Clinical Medicine and Management, p 1155-1163. Elsevier, St. Louis, MO. First ed. 2012
8. Villalobos, A. Pawspice. http://aplb.org./resources/quality-of-life_scale.php
NOTES:
33
NOTES:
34
Death & Dying: Feline Euthanasia in the Clinical Setting

Elizabeth Colleran, DVM, MS, DABVP (Feline)
In an AVMA sponsored conference on euthanasia, slaughter and depopulation called “Humane Endings” in
October 2014, the keynote speaker described the change in public perception of the importance of animals of all
kinds. He described the increasingly pervasive public perception of animals as connected to humans and the
associated increased public aversion to animal deaths and killing. He concluded that animal death and killing will
become more emotional and more contentious. While his remarks were directed at all the participants, the
implications for the experience clients have of euthanasia are clear. Our obligation to provide a painless death for the
beloved animal and an acceptable experience for owners of companion animals is becoming more complex.
With the decreasing nuclear family, an outcome of the decline of agricultural community, the rise of
industrialization, and climbing divorce rates and prolonged life spans, comes the increase in isolation from family,
neighbors and community. Yet people need love, companionship and emotional support. This has given rise to the
redefinition of pets as family members. About 90% of respondents in one study of 100,000 US households rated a
pet as important or extremely important to the family. For many complex reasons, the emotional attachments which
many humans develop for their pets not only equals but frequently transcends the emotional attachment which they
form with humans and can be a source of unconditional love, support, comfort, safety, security and stability.
When highly attached owners recognize that a moment has arisen in the clinical management of a life-
limiting medical condition when a cure is not an attainable goal, it is normal for them to experience strong emotions,
generally termed anticipatory grief. Anticipatory grief is the psyche’s way of preparing for impending loss. This is
often the beginning of a period of powerful emotional states, which can blur judgment at a time when clear thinking
and planning may be key to resolution of grief and ending the suffering of a beloved pet.
Pet owners often trust veterinarians and/or see them as authority figures. During loss, clients may look to the
veterinarian to provide strength, guidance, and leadership. 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.
The owner becomes the animal’s proxy and will decide if and when euthanasia is a better option than life for
an animal that is suffering despite receiving the best comfort care available. The strongest desire of highly attached
pet owners facing the loss of a beloved pet is to do what is best for the animal. It is an elusive goal and one, which
requires the owner’s interpretation of the animal’s state.
A veterinarian can help by educating an owner in how to assess quality of life, attributing relative weight to
specific experiences like the presence or absence of joy, pain, or frustration. In the general practitioners’
relationships with clients there is very often a long more intimate connection than there is with specialists to whom
the animal may have been referred for care. Therefore, the generalist should stay involved after a referral and
advocate for what is right for the pet. This is also important for the emotional state of the owner. Powerful emotions
can ensue when decisions are second-guessed. Decisions made too early may cause profound guilt. A decision
thought to be made too late may be interpreted as causing suffering for a beloved family member. The uncertainty
that is a natural part of being a proxy for another’s best interest is always present.
The skills of educating, supporting, guiding and facilitating are key to assisting the client. More importantly,
the veterinarian must not try to solve the owner’s problems by making decisions for them, by giving them advice on
what course they should take, rationalizing their choices or rescuing them. Presenting options gives families control
over the process leading to inevitable loss by helping them find their own view of what constitutes the best way to
care for their animal. A sense of control – even if limited – has been shown to correlate with healthy grieving and
emotional healing. The manner in which a veterinarian provides care for a client whose pet has died has the potential
to alleviate or aggravate grief, influence client and veterinarian satisfaction and create or destroy long-lasting
relationships.
It is essential to listen to what is most important to the family under the circumstances, what their concerns
are, how they want to spend their time as options become limited and what kind of tradeoffs they are willing to make.
The sense of control should extend to the physical and social environment surrounding a beloved pet during the last
moments. Planning in advance, before powerful emotions hold sway over decisions, will allow the family to think
clearly through their plan. As emotional states become more ascendant, remind the owners of their decisions. They
may choose the form of death, natural or euthanasia, who should be present, the tenor of the ritual and whether
children should be involved. If euthanasia is elected, the mechanics of the process should be discussed. The location
may be of concern as well, whether outdoors, in the owner’s lap, at home, on the floor. Conventional rituals that
support and comfort people at the time of the loss of a human loved one, funerals, calling hours, or celebrations of
life, have not evolved around pet loss. This one event may be all the ritual possible for a highly attached client whose
family may not perceive the death as a loss of a loved one.
35
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. Premedication with an anxiolytic and/or
analgesia/anesthesia is a powerful tool to prevent these negative emotional states. Acepromazine has a long onset
of action 15 minutes after IV administration and 30 to 45 minutes after intramuscular administration; it should be
avoided unless the owner wishes a longer period of time to say goodbye. A combination of midazolam (0.2– 0.3
milligrams/kilogram) and telazol (3 to 5 mg per kilogram) diluted to reduce any sting and given subcutaneously is a
common combination. A combination of benzodiazepine and an opioid is also common. Subcutaneous injections
reduce the chance of causing discomfort, as does dilution.
In severely debilitated cats, it is possible that the premedication may have sufficient cardiac and respiratory
effects for the cat to die prior to the administration of a euthanasia solution. Therefore, the owner should be prepared
for this possible outcome prior to administering the injection. After administering the premedication, sufficient time
must be allowed for it to take effect. This time maybe welcomed by the owner as a time to be alone with their beloved
cat and say their last goodbyes.
There is controversy surrounding the placement of an intravenous catheter for the purpose of euthanasia.
Unless there is a catheter present, this author does not advocate placement for the following reasons:
• Many veterinary nurses/technicians have difficulty placing catheters in the presence of an owner,
• Alternatively, taking the cats away from the owner for a catheter to be placed elsewhere may be very difficult
for the owner tolerate,
• 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,
• Many cats at the end of their life, for many reasons, have poor peripheral veins, making catheter placement
very challenging,
• The type of restraint required for accurate catheter placement maybe painful for an elderly or otherwise
debilitated cat
Using a butterfly catheter and a medial saphenous vein, the owner can be closest to the cranial part of the
cat and able to stroke, speak to or hold their cat. Prior to euthanasia, the owner must understand if they have never
experienced it before, that intravenous euthanasia causes instantaneous death. They must have had their final
moments prior to administration. Intraperitoneal euthanasia with a non-irritating barbiturate has been advocated by
some as a humane approach. The time to death is longer and once again the owner must be informed. Recently, a
home euthanasia veterinarian reported 131 cats euthanized via intrarenal injection of sodium pentobarbital. The cats
were anesthetized with a combination of telazol and acepromazine given subcutaneously. Time to cardiopulmonary
arrest was less than one minute. 95% of the cats showed no physical reaction to the injection and 56% died before
the completion of the injection. Kidney size, dehydration, and wait were not factors in successfully completing the
procedure. Further investigation into this form of euthanasia is needed.
The final obligation of the attending veterinarian is to ensure that death is confirmed. During the final
consolation process, lack of pulse, cessation of breathing, an absence of heartbeat and palpebral reflex must be
accomplished. The decision regarding disposition of remains should have been made ahead of time. If the owner
has decided to dispose of their cat home, providing a nice burial box avoids any awkwardness at departure. The
owner may need a period of time prior to departure to collect themselves and recover enough to leave safely. If
possible, the owner should be escorted to the quietest exit without any need to interact with the staff or other clients.
References
1. AVMA Guidelines for Euthanasia; 2013 Edition
2. Shearer, Tamara. Veterinary Clinics of North America Palliative Medicine and Hospice Care. Philadelphia:
WB Saunders 2011.
3. Little, Susan, ed. The Cat Clinical Medicine and Management, 1st ed. St. Louis: Elsevier, 2012.
4. McMillan, Franklin. Rethinking Euthanasia:Death as an Unintentional Outcome. JAVMA 2001: 219(9): 1204-
1206
5. Wrobel TA, et al. Grieving Pet Death: Normative, Gender, and Attachment Issues. Omega 2003;47(4):385-
393
6. Gage, MG, et al. Couples’ Preception of Stressfulness of Death of the Family Pet. Family Relations 1991: 40
(1): 103-105
NOTES:
36

Margie Scherk DVM, DABVP (Feline)
Food, Eating, and Nutrition in a Feline Context

Cats diverged from dogs approximately 30 million years ago, evolving metabolically into obligate carnivores
with unique strategies to utilize amino acids, fats, carbohydrates and vitamins. In understanding the nutritional needs
of cats and planning dietary therapies for health and illness, it is important to realize that domestic cats have not
evolved from the wild-cat model.
Being small in size, these predators are preyed on by other predators. Their size along with being obligate
carnivores has affected everything about cats: their social structure, their hunting behavior, that they eat many small
meals a day, that they eat alone, the small size of their stomach, their lack of salivary amylase, their dentition. They
hunt throughout the day and night, esp. at dawn and dusk (“crepuscular”), when their prey are active. Small rodents
and birds make up the majority of their diet, with rabbits, insects, frogs and reptiles making up a smaller proportion.
Cats are hunters, yet the drive to hunt is independent from eating. Feeding more food doesn’t stop them from
killing birds or mice; it merely results in weight gain. Most cats need 10-15 attempts to be successful at catching
prey; the drive to “eye, stalk, pounce and kill” is permanently “turned-on” to avoid starvation. Repeated hunting
throughout a 24-hour period is needed to meet this need, and results in the normal grazing behaviour of domestic
cats. The average mouse provides 30-35 kcal; as cats need ~50 kcal/kg ideal weight/day, the 5 kg cat needs 250
kcal or 8 mouse-sized portions/day. These meals are spread out throughout the day, not consumed all at once.
Neither feeding twice a day nor having the bottomless bowl are “natural” ways for cats to eat. A 30 kcal meal
is approximately 10 pieces of an average maintenance dry food; even eating 10 extra pieces/day results in a 10% (1
lb) weight gain/year. The difference in the human social structure, culture and relationship with food is very different
from that of a solitary hunter. Cats generally interact with us frequently and at a low intensity/casually; people
generally want fewer, more intense/focused periods of interaction with them. Eating is not a social activity for cats.
Our need for interaction with our cats also contributes to obesity. We may feel like a bad provider or rejected if our
cats don’t eat their food eagerly and seek second helpings. And, because their meal size is meant to be small, we
misunderstand and want them to eat more. We try different diets until we have “evidence “ that they enjoy their food.
We train them to ask for food and they train us to respond to their boredom or other unmet needs by feeding them.
Numerous studies have been performed all showing that spaying and neutering/castration decrease energy
expenditure by 7-33%. It is, therefore, very important to counsel clients to change from a growth to an adult
formulation and to restrict the caloric intake after surgical altering. In general, unaltered cats need 60-80 kcal/kg/day;
after altering, they need about 40-50 kcal/kg ideal body weight/day. A better formula is shown in Table 1.
Opportunities to express hunting behaviour are a basic need for a cat. If a cat doesn’t have the opportunity
to hunt, toys meeting appropriate criteria are small (prey-sized), make high-pitched squeaks or cheeps and move in a
rapid, unpredictable fashion. The Indoor Pet Initiative offers an informative piece on choosing the correct toy for an
individual cat: http://indoorpet.osu.edu/cats/basicneeds/preypref/index.cfm. Allowing them to hunt for their food (bowl)
or using a feeding toy are mentally stimulating activities. Examples of feeding toys include:
· Multivet Slim Cat (http://www.petsafe.net/Products/Feeders/SlimCat.aspx)
· Cat Activity Fun Board (http://www.traininglines.co.uk/cat-activity-fun-board-3397-0.html)
· Go!Cat!Go! Play-N-Treat balls
· FUNkitty Egg-Cersizer: (http://www.premier.com)
· Aikiou Stimulo (http://aikiou.com/stimulo-cat-bowls-and-feeders/)
· Catit Design Senses Food Maze (http://ca-en.hagen.com/Cat/Feeding/Accessories/50745)
Cats are very sensitive to the feel of a food (physical form), its odour and taste. They eat their prey head-
first. This is a tactile response to the sensation from the direction of the hair/feathers. Most cats prefer foods that are
solid and moist, like flesh, not powdery, sticky or greasy. They prefer their food at fresh-killed body temperature
rather than room temperature or out of the refrigerator or hot.
Under stressful situations, cats will refuse a novel food; under other circumstances, the same cat may be
very adventuresome and chose a new diet over their familiar food. A new diet is more likely to be accepted if it is
offered at home rather than in the clinic setting.
Uniquely Feline
Cats have obligatory dietary requirements for nutrients that are not essential for many other species
including specific amino acids (carnitine, arginine, taurine) and some vitamins (niacin, A and D). They also have a
higher maintenance requirement for protein than omnivores do. Dietary protein is required to provide essential, non
37
disposable amino acids (those that the body can’t synthesize on its own) as well as “disposable” nitrogen to build
1
those amino acids and other nitrogen-containing compounds that it is able to synthesize .
Urea cycle enzymes in the liver of cats are always „turned on“. Cats are able to adapt their protein oxidation
2
to a wide range of dietary protein concentrations, provided their minimum protein requirement is met . If dietary
intake is below their protein requirement, they are unable to decrease protein oxidation enough to maintain a neutral
nitrogen balance. In other words, they are flexible in their ability to up-regulate the urea cycle in face of high protein
meals (the native diet), in order to protect themselves from ammonia toxicity; they use the carbon skeletons from
amino acids for gluconeogenesis. This has been termed “hypercarnivorism”.
While other species are able to rest their metabolic pathways from the efforts of glucose (energy) synthesis
when they have been fed, cats must continue gluconeogenesis in both the fed and fasted states. When anorectic,
3
they catabolize body proteins. Protein supplementation during fasting will actually slow hepatic lipid accumulation . A
recent hypotheseis states that “cats do not have a high-protein requirement per se, but rather a secondarily high
elevated protein requirement in response to a high endogenous glucose demand” because of a relatively larger brain
4
for a mammal of its size resulting in a ready need for glucose . As such, they have developed metabolic strategies
that avoid ketonemia and amino acids are used for gluconeogenesis to meet the endogenous glucose demand
independent of dietary carbohydrate intake. This evolutionary strategy reflects survival on a high-protein, low
carbohydrate, prey-based diet for a small mammal with a large brain.
“Natural” Nutrition: Macronutrient Profiles

What is known about the composition of their meals in nature? What proportion of the energy sources
protein, fat and carbohydrates (macronutrients) is ideal for a cat? In their native state, cats rely on a diet solely
based on animal tissues to meet their nutritional requirements. In an attempt to evaluate the dietary nutrient profile of
free-living cats, Plantinga assessed 27 studies that looked at the diets of wild or feral cats. Results showed that feral
cats receive their daily energy from crude protein (52 %), from crude fat (46 %) and from nitrogen-free extract only 2
5
%. This reflects the nutrient intake to which the cat’s metabolic system has adapted .
Two further studies have been done regarding macronutrient (protein, fat and carbohydrates) profiling. In the
first, in an experimental setting, when cats were allowed to choose one of several diets (each having a different
macronutrient proportion), they consistently chose to eat a diet made up of 50% protein, 40% fat and 10%
carbohydrate. When this preferred diet was made less palatable by adding aversive flavouring and the less desirable
lower protein diet was flavoured with a favourite flavour, the cats learned quickly to select the nutritionally beneficial,
6
rather than the tasty, hedonistically preferable diet .
The same group then went on to determine whether cats were able to do the same with different textures and
moisture content and found that cats were able to regulate food selection and intake to balance macronutrient intake
7
despite differences in moisture content and textural properties of the foods provided .
Health and Disease

In growth, as in other species, kittens need more protein than their adult counterparts. As adults, cats need
more than twice the adult canine or human requirements. As the ability to digest protein (and fat) declines in some
8
elderly cats, even healthy seniors may actually need more protein than adult cats do .
If a cat is getting enough calories, but not enough of them come from protein, “protein: calorie malnutrition”
may ensue. There may or may not be weight loss, but there will be muscle wasting as well as a deterioration in hair
coat quality. Because protein is a key component in antibodies, immune function may be compromised; anemia may
be exacerbated due to the lack of building blocks for hemoglobin; albumin levels may decrease and tissue healing
will be affected. Protein is a preferred macronutrient, so if a cat is already inappetant, restricting protein may result in
inadequate intake of all nutrients, and the protein intake may fall below that required for normal function.
Protein levels in “restricted” and “high” protein diets fall within the nutritional guidelines, merely at the low or
at the high end of the range. Protein-restricted therapeutic diets are not all the same; there are some marked
differences in their composition, not just in protein sources and quantities, but also in the calorie source, in their
phosphorus, potassium, and sodium content.
Chronic Kidney Diseases

As an obligate carnivore, if a cat doesn’t get enough dietary protein to meet metabolic requirements, he must
draw on endogenous (stored) protein sources to meet those needs. The resulting muscle wasting and decreased
mass reduces the serum level of creatinine (Cr) measured. This makes it difficult to know how much of that decrease
in Cr in a cat fed a restricted protein diet is from improvement in renal function and how much is because there is
less functional muscle producing Cr. Dietary protein is not, in and unto itself, toxic to kidneys.
Despite numerous experimental studies and clinical trials having been performed, questions about feeding
protein to the cat with chronic kidney disease (CKD) still remain. These include the following:
1. What is optimal amount of protein for cat with CKD? How much restriction is necessary?
2. Do different types of kidney disease require different dietary therapies?
38
3. At what point in disease progression should protein restriction be implemented?
4. Does the type of protein fed make a difference?
5. Does every meal have to be restricted?
6. Will a cat in IRIS stage 3 or 4 benefit if phosphorus is restricted by other means?
7. Might some cats with advanced disease benefit from increased protein levels?
In mild to moderate CKD (IRIS Stage 1, early stage 2) restriction of dietary protein, may limit the kidney's
compensatory response. It is reasonable to consider protein restriction if moderate azotemia persists in the stable,
well-hydrated state (late IRIS Stage 2-Stage 3), however the cat should be reassessed to see if the diet is beneficial
or not. In Stage 4, dietary recommendations are not controversial: restriction of both protein and phosphorous are
required to ameliorate the clinical signs of uremia. Nevertheless, individualization is needed because excessive
protein restriction for an inappetant individual may be harmful, when sustained calorie deficit causes catabolism of
body proteins for calories and the resulting nitrogenous end-products further aggravate uremia. Uremia is associated
with variable dietary intake, intestinal malabsorption, metabolic acidosis and co-morbid conditions, which
independently influence nitrogen balance. A balance needs to be found between reducing protein intake and the
patient’s willingness to eat and enjoyment of life. If the cat is unwilling to eat adequate quantities of food, then he/she
will have inadequate intake of all nutrients and will take in even less protein than was intended. Increasing fat
content provides additional non-protein calories and may benefit palatability.
If a cat is getting enough calories, but not enough of them come from protein, protein: calorie malnutrition
may ensue. There may or may not be weight loss, but there will be muscle wasting as well as a deterioration in the
hair coat quality. Because protein is component in antibodies, immune function may be compromised; anemia may
be exacerbated due to the lack of building blocks for hemoglobin; albumin levels may decrease and tissue healing
will be affected. Protein is a preferred flavour, so if a cat is already inappetant, restricting protein may result in
inadequate intake of all nutrients, and the protein intake may fall below that required for normal function.
Obesity
The role of protein in weight loss and prevention of rebound weight gain is controversial. Some human
studies have suggested that when reducing caloric intake, feeding a higher protein diet is beneficial because
digesting protein (thermic effect) requires more energy than digesting other macronutrients resulting in greater weight
loss (or less chance of regaining lost weight) and because protein increases satiety.
In cats the evidence is variable. One study showed that despite eating more of a higher protein diet,
presumably due to increased palatability, there was no increase in body weight, suggesting that a higher protein diet
9
results in a greater energy expenditure . Other studies show that higher levels of protein induce satiety resulting in
fewer calories ingested when fed ad libitum. Greater amounts of fat were lost on an isocaloric, higher protein diet,
10-12 13
sparing lean body mass in three other studies , however, this beneficial effect was not found in a fourth study . In
summary, current evidence suggests that feeding diets with > 40% (on an energy basis) protein is important to help
maintain lean body mass during weight loss.
Diabetes
In the past, increasing dietary fiber was considered appropriate for feeding cats with diabetes. In 2006, a study
showed that over a 16-week period, significantly more diabetic cats who were fed a low carbohydrate, low fiber diet
14
had reverted to a non-insulin-dependent state than cats fed a moderate carbohydrate, high fiber diet . As pertains to
protein, as early as 1980, a study comparing rats (omnivores) and normal cats had already shown that, compared to
controls given carbohydrate-rich diets, animals fed a high protein diet had, in the fed state, lower levels of blood
15
sugar than those fed a control diet . And in one other study, insulin levels were decreased in diabetic cats when
transitioned from a high-fiber diet to a high-protein diet with insulin injections being discontinued in 1/3 of the cats.
Insulin doses overall could be reduced by over 50% with no loss in glucose control, as measured by serum
16
fructosamine . However, most recently, a small study comparing the effects of feeding a low carbohydrate-high
protein diet to feeding a control, commercial diet in diabetic cats found no significant difference between response
and suggested that frequent monitoring was the key to achieving glycemic control in diabetic cats and that potential
17
benefits of dietary modification require further evaluation . In summary, while diabetic cats can be regulated using
any diet consistently, there appears to be a benefit to feeding a higher protein, lower carbohydrate diet. If a cat is
overweight/obese, weight loss will improve cell insulin receptor sensitivity.
How Much to Feed

A rough guide to use is to feed 50 kcal/kg ideal weight/day. Laflamme has shown that healthy adult cats need
at least 5.2 g protein/kg to maintain nitrogen balance or lean body mass. This is substantially higher than current
AAFCO and NRC recommendations. The effect, if any, of body condition, age and gender on protein requirements,
18
needs to be further researched . This “rule-of-thumb” is adequate for calculations to determine how much a patient
should be getting on a daily basis in clinic and as a starting point for the patient when they are discharged. The client
should be advised of the actual amount of food to feed when sent home with canned or dry food. Make sure that you
39
are communicating with common vocabulary as what one person thinks of as a “cup“ may not be an 8 oz/250ml
measuring cup.
For cats outside of the 4-5kg (9-11lb) range in ideal condition, the 50 kcal/kg/day isn’t accurate enough.
0.75
Caloric requirements for maintenance are closer to: 70 (BW in kg) (Table 1.)
Example: for a lean 18 lb (8.1 kg) cat:
8.1 X 8.1 X 8.1 = BW cubed = 534.4
Hit square root button twice => 23 then => 4.8
4.8 X 70 = 336.
Had one used 50 kcal X 8.1 kg = 405 kcal, the cat would get 20% more than needed.
Table 1: Resting Energy Requirements (RER) for Ideal Body Weight

Cat BCS 2.5/5 to 3.5/5 or 5/9 RER*
Body weight (lbs) Body weight (kg) Kcal/day
1 0.45 39
2 0.91 65
3 1.36 88
4 1.82 110
5 2.27 130
6 2.73 149
7 3.18 167
8 3.64 184
9 4.09 201
10 4.55 218
15 6.82 295
20 9.09 366
25 11.36 433
RER = [BW(kg)0.75 * 70]
Growth DER (Kcal/day): Growing kittens = 2.5 X RER

Maintenance DER (Kcal/day):
Normal, neutered adult = 1.2 X RER
Intact adult = 1.4 X RER
Obese prone = 1.0 X RER
For weight loss = 0.8 X RER
RER- Resting Energy Requirement: the energy required for a normal individual at rest in a thermoneutral
environment based on body weight.
DER – Daily Energy Requirement: the average daily energy expenditure of an animal dependent on lifestage and
activity (work, lactation, gestation, growth).
To calculate the caloric requirement for an overweight/obese cat to lose weight, use the 60-70% of
maintenance requirement for their ideal weight.
When a cat is underweight or inappetant, appetite stimulants (e.g., cyproheptadine: 1 mg/cat PO q12h;
mirtazapine (2-4 mg/cat PO q72h) may help jump-start a cat’s appetite, but one must be wary not to lose sight of total
calories consumed. If a cat is eating but not enough, supportive feeding (assisted syringe feeding or tube feeding)
should be considered. Esophagostomy (or other tube) feeding should not be reserved as an heroic or last-ditch
recommendation. Earlier intervention provides better outcomes.
When a cat is eating any therapeutic diet, it is very important to check and see how the individual patient is
responding to that diet by reevaluating them, just as we would recheck a patient on any other medical therapy.
Checking body weight and condition cannot be done over the phone.
While animals, (cats included), can adapt to low dietary protein and maintain nitrogen balance while
depleting lean body mass, loss of lean body mass and an associated reduction in protein turnover can result in
18
compromised immune function and increased morbidity . Cats truly rely on protein as the pillar of their nutritional
platform.
References
1. Morris, JG. Idiosyncratic nutrient requirements of cats appear to be diet-induced evolutionary adaptations.
Nutr Res Rev. 2002, 15:153-168.
2. Green AS, Ramsey JJ, Villaverde C, et al. Cats Are Able to Adapt Protein Oxidation to Protein Intake
Provided Their Requirement for Dietary Protein Is Met. J. Nutr. 2008, 138: 1053–1060.
40
3. Biourge VC, Massat B, Groff JM, et al. Effects of protein, lipid, or carbohydrate supplementation on hepatic
lipid accumulation during rapid weight loss in obese cats. Am J Vet Res. 1994, 55 (10): 1406-15.
4. Eisert R. Hypercarnivory and the brain: protein requirements of cats reconsidered. J Comp Physiol B. 2011,
181: 1–17.
5. Plantinga EA, Bosch G, Hendriks WH. Estimation of the dietary nutrient profile of free-roaming feral cats:
possible implications for nutrition of domestic cats. Br J Nutr. 2011, 106: S35–S48.
6. Hewson-Hughes AK, Hewson-Hughes VL, Miller AT, et al. Geometric analysis of macronutrient selection in
the adult domestic cat, Felis catus. J Expl Bio. 2011, 214: 1039-1051.
7. Hewson-Hughes AK, Hewson-Hughes VL, Colye A, et al. Consistent proportional macronutrient intake
selected by adult domestic cats (Felis catus) despite variations in macronutrient and moisture content of
foods offered. J Comp Physiol B. 2013, 183:525–536
8. Perez-Camargo G. Cat nutrition: What’s new in the old? Comp Cont Edu Sm An Pract. 2004, 26 (Suppl 2A):
5-10
9. Wei A, Fascetti AJ, Liu KJ, et al. Influence of a high-protein diet on energy balance in obese cats allowed ad
libitum access to food. J Anim Physiol Anim Nutr. 2011, 95: 359–36.
10. Laflamme DP, Hannah SS. Increased dietary protein promotes fat loss and reduces loss of lean body mass
during weight loss in cats. Intern J Appl Res Vet Med. 2005; 3: 62-68.
11. Vasconcellos RS, Borges NC, Gonçalves KNV, et al. Protein intake during weight loss influences the energy
required for weight loss and maintenance in cats. J Nutr. 2009, 138: 855-860.
12. Hoenig M, Thomaseth K, Waldron M, et al. Insulin sensitivity, fat distribution, and adipocytokine response to
different diets in lean and obese cats before and after weight loss. Am J Physiol Regul Integr Comp Physiol.
2007, 292: 227-234.
13. Nguyen P, Leray V, Dumon H, et al. High Protein Intake Affects Lean Body Mass but Not Energy
Expenditure in Nonobese Neutered Cats. American Society for Nutritional Sciences. J. Nutr. 2004, 134:
2084S–2086S.
14. Bennett N, Greco DS, Peterson ME, et al. Comparison of a low carbohydrate–low fiber diet and a moderate
carbohydrate–high fiber diet in the management of feline diabetes mellitus. J Feline Med Surg. 2006, 8: 73-
84.
15. Kettelhut IC, Foss MC, Migliorini. RH. Glucose homeostasis in a carnivorous animal (cat) and in rats fed a
high-protein diet. AJP - Regu Physiol. 1980, 239: R437-R444.
16. Frank G, Anderson W, Pazak H, et al. Use of a high-protein diet in the management of feline diabetes
mellitus. Veterinary Therapeutics: Research in Applied Veterinary Medicine 2001, 2:238-246.
17. Hall TD, Mahony O, Rozanski EA, et al. Effects of diet on glucose control in cats with diabetes mellitus
treated with twice daily insulin glargine? J Feline Med Surg. 2009, 11: 125-130.
18. Laflamme DP, Hannah SS. Discrepancy between use of lean body mass or nitrogen balance to determine
protein requirements for adult cats. J Feline Med Surg. 2013, 15: 691-697.
NOTES:
41
NOTES:
42
Emerging Infectious Diseases

Susan Little, DVM, DABVP (Feline)
Introduction
According to the Centers for Disease Control and Prevention (www.cdc.gov), emerging diseases are those
that have increased in incidence in the past two decades or that threaten to increase in the near future. These
diseases may be:
1. New infections resulting from changes or evolution of existing organisms (e.g., severe acute respiratory
syndrome, acquired immunodeficiency syndrome, Middle East respiratory syndrome)
2. Known infections spreading to new geographic areas or populations (e.g., West Nile virus)
3. Previously unrecognized infections appearing in areas undergoing ecologic transformation (e.g., Lyme
disease)
4. Old infections re-emerging as a result of antimicrobial resistance in known agents or breakdowns in public
health measures (e.g., drug resistant tuberculosis)
Anaplasma phagocytophilum
Several rickettsial organisms have been identified in cats in North America, such as Anaplasma
1
phagocytophilum, Anaplasma platys, Ehrlichia canis, Ehrlichia chaffeensis, and Ehrlichia ewingii . With the exception
of Bartonella spp. or Cytauxzoon felis, vector-borne pathogens have not been as well studied in cats as in dogs and
are often over-looked as a potential cause of illness. A. phagocytophilum is transmitted by Ixodes spp. ticks and has
been associated with clinical disease in humans, ruminants, horses, dogs, and cats. A. phagocytophilum is
transmitted by the black-legged tick (Ixodes scapularis) in the Northeast and the western black-legged tick (Ixodes
paciﬁcus) in the West. Infections are highest in the late spring and fall when both nymph and adult ticks are most
2
mobile. Prevalence can be as high as 38% in the endemic regions of the Northeastern United States.
Currently, veterinary diagnostic laboratories use A. phagocytophilum antigens and assays that were
validated for testing in dogs and that may not have not been optimized for testing cats, although they are commonly
used in this species. It is also important to note that cross-reaction among the Ehrlichia spp. and Anaplasma spp. is
common, and nonspecific IFA titers may develop. Antibody titers may persist for months to years after treatment and
resolution of clinical signs, possibly due to chronic infection or re-infection. The presence of antibodies alone does
not indicate a need for treatment unless the patient has compatible clinical signs.
Many reports of natural feline anaplasmosis in Europe have been published, but reports from North America
are scarce. One of the first reports of A. phagocytophilum infection documented acute onset of fever and
3
thrombocytopenia in 4 cats living in Massachusetts and Connecticut that responded to treatment with doxycycline. A
2011 report detailed 123 cats (84 healthy, 39 sick) tested for A. phagocytophilum with the IDEXX SNAP 4Dx in
4
Portland, Maine. Both healthy and sick cats were found to be seropositive, but seropositivity was statistically more
likely in sick cats (those with fever, lameness, lethargy, inappetance, or presence of an Ixodes tick). Recently, the
first report was published describing A. phagocytophilum morulae in neutrophils of 16 cats in North America with
5
natural infections confirmed by PCR testing. Common clinical signs included lethargy, anorexia, and fever. Less
common clinical findings included hepatosplenomegaly, ataxia, conjunctivitis, and elevation of the nictitating
membranes. Complete blood count abnormalities included lymphopenia, thrombocytopenia, neutropenia, and
leukopenia. Morulae were identified in the neutrophils of 3 cats. All cats treated with doxycycline (14/16) responded
with resolution of clinical abnormalities.
Ixodes ticks carry Borrelia (the cause of Lyme disease), the most prevalent arthropod borne infection of
humans with 30,831 cases reported to the Centers for Disease Control and Prevention in 2012. Increasing cases of
Lyme disease in southern states, including Texas and also Mexico, are a cause of concern that the tick range may
be expanding. Practitioners should be aware that feline anaplasmosis may be present in areas where it is currently
overlooked.
Invasive Aspergillus Infections

Aspergillosis is an opportunistic infection of cats, dogs, and humans found world-wide. Most infections are
due to A. fumigatus. Aspergillosis is the most common invasive fungal infection in immunosuppressed humans and is
also associated with tuberculosis and chronic obstructive pulmonary disease. The disease is not zoonotic as only
environmental spores are contagious, not infected patients.
In 2012, a report from the University of Sydney, Australia described two forms of invasive aspergillosis in
6
cats: sinonasal and sino-orbital. Since that time, invasive aspergillosis has been reported in cats in the U.S., U.K.,
Europe, and Japan. Brachycephalic breeds such as the Persian appear to be predisposed. The median age of
43
affected patients is 6.5 years; there is no sex predilection. Cats are exposed by inhaling fungal spores from pet food,
cat litter, or the environment. The spores (conidia) are very small and able to stay airborne so they are easily inhaled.
The sinonasal form is usually localized and carries a better prognosis than the sino-orbital form. Clinical
signs with the sinonasal form include sneezing, serous to mucopurulent nasal discharge (uni- or bilateral), and
7
stertor. Less common clinical signs include epistaxis, a mass protruding from the nostril, and bone lysis. Typically, A.
fumigatus is isolated from this form of the disease. Treatment may involve systemic antifungal drugs (e.g.,
itraconazole or posaconazole alone or in combination with amphotericin B) and topical intranasal clotrimazole
infusion. Debridement of lesions in the nasal cavity is important. Combining topical and systemic therapy is
recommended to prevent the localized sinonasal form from progressing to the sino-orbital form.
The sino-orbital form (invasive fungal rhinosinusitis) is more generalized and carries a poorer prognosis.
Most cats are presented for clinical signs associated with invasive retrobulbar granuloma formation (e.g., unilateral
exophthalmos, oral mass, mandibular lymphadenopathy). Clinical signs are also seen in the ipsilateral eye (e.g.,
conjunctival hyperemia, prolapse of the nictitating membrane, exposure keratitis). Less common clinical signs include
fever, bilateral exophthalmos, ulcerated hard palate, and neurologic signs. The sino-orbital form follows a more
protracted disease course and is often resistant to commonly used antifungal drugs. Most patients are euthanized
due to disease progression, including blindness and seizures.
In 2013, researchers at the University of Sydney, Australia determined that the sino-orbital form of
8
aspergillosis is often caused by a novel Aspergillus species, tentatively called A. felis. Feline cases of A. felis have
now been identified in Australia and the U.K. and the infection has been documented in dogs and humans. The
fungus has also been isolated from a home in Germany. Given the difference in clinical course and prognosis
between A. fumigatus and A. felis, identification of the species in affected cats using molecular assays is
recommended.
Aelurostrongylus abstrusus Infection

Aelurostrongylus abstrusus is a metastrongyloid nematode parasite found world-wide. It is the most common
feline pulmonary parasite and appears to be increasing in prevalence, possibly due to factors such as global
warming, changes in vector seasonal population dynamics, and movements in animal populations. In recent years,
9
high rates of infection have been documented in countries such as Italy, Portugal, and Albania. This lungworm has
also been identified in many areas of Canada and the U.S. In endemic areas, the prevalence of infection may be as
high as 20-50%, representing a significant cause of respiratory disease.
Cats are infected with A. abstrusus by eating snails, slugs or paratenic hosts (e.g, frogs, toads, lizards,
snakes, birds, mice). Infective larvae penetrate the gastrointestinal tract and migrate to the lungs where they mature.
Female worms deposit eggs in the lung parenchyma starting 4 weeks after infection. The first stage larvae hatch and
are carried up the tracheobronchial tree and swallowed; they appear in cat feces 6 weeks after infection. The larvae
must then enter a snail or slug to develop to the infective form over the next 2-5 weeks.
Clinical signs may be absent in very mild cases, but more typically involve cough and anorexia due to
bronchiolitis and interstitial pneumonia. Severely affected cats may have cough, dyspnea, polypnea, anorexia,
emaciation, and a heart murmur (due to pulmonary hypertension). Radiographs show a mixed pulmonary pattern. An
alveolar pattern predominates during the period of heaviest larval shedding (5-15 weeks post-infection), then
bronchial and interstitial patterns develop. On necropsy, lung lobes may be diffusely firm and non-collapsing with
10
multifocal to coalescing, tan to white nodules that may be up to 1 cm in diameter. Examination of impression
smears from the cut surface of the lung reveals larvae and embryonated eggs. Adult worms live in the terminal
bronchioles. Severe and permanent lung lesions, sometimes leading to death, can occur if the disease is not
identified and treated.
Diagnosis of A. abstrusus infection is best accomplished using a Baermann technique on feces or a direct
11
fecal smear to identify larvae. Flotation and sedimentation techniques for examining feces are not optimal for
identification of this parasite. Direct examination of fluid obtained during bronchoalveolar lavage may identify adult
worms. Antibody assays are not useful as antibody titres persist long after the infection is cleared.
Many drugs are useful for the treatment of A. abstrusus infections, such as fenbendazole (50 mg/kg/day for
10-20 days). Ivermectin is not recommended due to mixed reports of efficacy. Topical products such as Broadline
(Merial), Revolution (Zoetis), Profender and Advantage Multi (Bayer) can also be used with 2 doses applied 3 weeks
apart. Prednisolone can be used to alleviate clinical signs if necessary (1 mg/kg/day for 5-7 days). A fecal sample
should be examined after completion of therapy to ensure treatment compliance and efficacy.
Feline Morbillivirus
Morbilliviruses are enveloped, single-stranded RNA viruses capable of causing severe disease in various
animal species (e.g., canine distemper, measles, rinderpest). However, this genus of virus was unknown in cats until
12
2012 when it was discovered in cats in Hong Kong and China in association with tubulointerstitial nephritis. Genetic
sequencing of the virus in these cats determined it was a previously unknown morbillivirus. In 2014, feline
13
morbillivirus was identified in urine, blood, and kidney biopsy samples of cats in Japan. Kidney cell cultures infected
with the virus showed cytopathic effects.
44
The implications of these findings are still unknown. Tubulointerstitial nephritis is the most common form of
kidney disease in the cat but the underlying cause is unknown in most cases. It is possible that morbillivirus is a
nephrotoxic virus in the cat that may trigger an immune-mediate process. Research is currently underway at Tufts
University to evaluated cats in the North Eastern U.S. for the presence of this virus and potential associations with
chronic kidney disease.
References
1. Hegarty BC, Qurollo B a., Thomas B, et al. Serological and molecular analysis of feline vector-borne
anaplasmosis and ehrlichiosis using species-specific peptides and PCR. Parasit Vectors 2015;8:320.
2. Magnarelli LA, Bushmich SL, Ijdo JW, Fikrig E. Seroprevalence of antibodies
against Borrelia burgdorferi and Anaplasma phagocytophilum in cats. Am J Vet Res. 2005;66:1895–9.
3. Lappin MR, Breitschwerdt EB, Jensen WA, et al. Molecular and serologic evidence of Anaplasma
phagocytophilum infection in cats in North America. J Am Vet Med Assoc 2004;225:893–896.
4. Hoyt K, Chandrashekar R, Breitschwerdt E, et al. Anaplasma phagocytophilum and Borrelia burgdorferi
antibodies in naturally exposed cats in Maine (abstract). J Vet Intern Med 2014;28:1068.
5. Savidge C, Ewing P, Andrews J, et al. Anaplasma phagocytophilum infection of domestic cats: 16 cases
from the northeastern USA. J Feline Med Surg 2015, in press.
6. Barrs VR, Halliday C, Martin P, et al. Sinonasal and sino-orbital aspergillosis in 23 cats: aetiology,
clinicopathological features and treatment outcomes. Vet J 2012;191:58–64.
7. Barrs VR, Talbot JJ. Feline aspergillosis. Vet Clin North Am Small Anim Pract 2014;44:51–73.
8. Barrs VR, van Doorn TM, Houbraken J, et al. Aspergillus felis sp. nov., an emerging agent of invasive
aspergillosis in humans, cats, and dogs. PLoS One 2013;8:e64871.
9. Traversa D, Di Cesare A, Conboy G. Canine and feline cardiopulmonary parasitic nematodes in Europe:
emerging and underestimated. Parasit Vectors 2010;3:62.
10. Rolim VM, Franca M, Brown HM, et al. Pathology in practice. Aelurostrongylus pneumonia in a cat. J Am Vet
Med Assoc 2012;241:1587–9.
11. Lacorcia L, Gasser RB, Anderson GA, et al. Comparison of bronchoalveolar lavage fluid examination and
other diagnostic techniques with the Baermann technique for detection of naturally occurring
Aelurostrongylus abstrusus infection in cats. J Am Vet Med Assoc 2009;235:43–49.
12. Woo PCY, Lau SKP, Wong BHL, et al. Feline morbillivirus, a previously undescribed paramyxovirus
associated with tubulointerstitial nephritis in domestic cats. Proc Natl Acad Sci 2012;109:5435–40.
13. Furuya T, Sassa Y, Omatsu T, et al. Existence of feline morbillivirus infection in Japanese cat populations.
Arch Virol 2014;159:371–3.
NOTES:
45
NOTES:
46
2015
3 WORLD FELINE
rd
VETERINARY
CONFERENCE FRIDAY, OCTOBER 2, 2015
COMBINED TRACK
Grand Hall C & D
7:30 – 8:00 am CONTINENTAL BREAKFAST in Grand Hall Foyer

President’s Address
8:00 – 8:10 am Dr. Susan Little
8:10 – 8:35 am General Session: Recent Compelling and Clinically Relevant JFMS Updates
Dr. Margie Scherk
General Session: Feline Pain Management Guidelines Sponsored by

8:35 – 10:00 am Dr. Michael Petty and Dr. Ilona Rodan
10:00 – 10:45 am NETWORKING REFRESHMENT BREAK in Exhibit Hall

TRACK A TRACK B
Thoracic Ultrasound: Feline Thoracic Feline Thoracic Radiographs: Interpretive
10:45 – 11:35 am Disease Principles & Normal Variations
Dr. Livia Benigni Dr. Lorrie Gaschen Sponsored by
Ultrasound of Feline Gastrointestinal, Improve Your Radiographic

11:40 – 12:30 pm Hepatic, & Pancreatic Diseases Interpretation of the Feline Abdomen
Dr. Livia Benigni Dr. Lorrie Gaschen

12:30 – 2:00 pm
12:45 - 1:45 pm Lunch & Learn: Sponsored by
Updates in Pain Management, Dr. Michael Petty - Hillcrest A

Imaging: Feline Urinary Tract Disease Obstructed or Not? Get the Most from
2:00 – 2:50 pm Dr. Livia Benigni Abdominal Radiographs
Dental Radiography Updates Improve Your Interpretation of

2:55 – 3:45 pm Dr. Brook Niemiec Radiographic Pulmonary Patterns in the Cat
Dr. Lorrie Gaschen
3:45 – 4:15 pm NETWORKING REFRESHMENT BREAK in Exhibit Hall

Feline Bones: Musculoskeletal Review Radiographic Interpretation of Heart

4:15 – 5:05 pm Dr. Zoe Lenard Sponsored by
Disease in Cats
Do Cats Have 9 Lives? Imaging Special Sonographic Features

5:10 – 6:00 pm in Cases of Feline Trauma of the Feline Abdomen
Dr. Zoe Lenard Dr. Lorrie Gaschen
Sponsored by
6:00 – 7:00 pm EXHIBITORS’ HAPPY HOUR RECEPTION in Exhibit Hall
American Association of Feline Practitioners October 1 – 4, 2015 www.catvets.com/education 47

Advanced Para-professional Generalist
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Feline Pain Management Guidelines

Michael Petty, DVM & Ilona Rodan, DVM, DABVP, ABVP (Feline)
Generalist
Combined
Introduction
1
Pain management is essential to patient welfare, successful case outcomes, and client satisfaction.
Although pain management in cats has lagged behind that of dogs, recognizing pain in cats, and advances in
prevention and treatment of feline pain can now be incorporated into each veterinary practice that sees cats.
Statistics vary, but up to 90% of cats in all age groups have some degree of osteoarthritis, more
appropriately termed degenerative joint disease (DJD). Beyond DJD are many other sources of pain, including acute
pain from injury or surgery and pain from other chronic diseases such as cancer. The 2015 AAFP Pain Management
Guidelines for Dogs and Cats is an up-to-date review of pain conditions and their treatments, including non-
pharmaceutical treatments. It also discusses gentle handling techniques and hospice care. This lecture is a review
of the Guidelines as it pertains to the feline patient.
Recognizing and Assessing Feline Pain

Recognizing Pain Through Behavior
Para-professional
1
• Changes in an individual cat’s behavior are the best method to identify pain in the cat,
• Changes can be either changes in normal behavior(s) or a start of a new, but abnormal behavior for an
2,3,4,5,6
individual cat.
Involve Owners in Pain Recognition

• Because the cat owner knows their cat and its normal behaviors better than anyone, it is important to include
2
them as an integral part of the healthcare team when it comes to recognizing pain.
• Studies indicate that clients can often identify pain in their own pets more accurately than veterinarians
3,4,5
can.
• Unfortunately, owners often consider the changes to be associated with “old age” rather than pain or illness.
It is our responsibility to educate them about “slowing down” and other behavior changes being common
signs of underlying pain.
Veterinary Teams and Pain Recognition and Assessment

• A comprehensive approach to identifying pain includes every member of the healthcare team in addition to
the client.
• All team members should be educated to recognize pain, and client education for early pain recognition is
also critical. Changes in behavior and behavior problems are the most important signs.
Recognizing and Assessing Acute Pain

• Whether acute pain occurs due to trauma, surgery, medical conditions, or diseases, the signs are similar.
The acute pain focus in the guidelines is on post-operative pain assessment.
• Assessment is based on patient observation and comparison with that patient’s “normal” prior to the
procedure. Observation should occur from a distance, then as a response to interactions such as talking to
the cat or opening the cage door, and then response to wound palpation.
• Assign a pain score based on the observations.
7,8
- A validated acute pain scale for cats, and pictures and videos are available to go with that scale.
http://www.animalpain.com.br/assets/upload/escala-en-us.pdf
http://www.animalpain.com.br/en-us/avaliacao-da-dor-em-gatos.php
- A non-validated acute pain score that is more readily usable is the CSU pain scale
https://www.csuanimalcancercenter.org/assets/files/csu_acute_pain_scale_feline.pdf
- Ggow pain scale for cats is in the process of being validated.
Advanced
8
• Signs of acute pain are squinted eyes and a hunched or tucked-up position.
Recognizing and Assessing Chronic Pain

• Pain scoring should also occur in all patients with chronic pain. Dr. Lascelles has developed a feline chronic
pain scale, Feline Musculoskeletal Pain Index (FMPI), http://www.cvm.ncsu.edu/docs/cprl/fmpi.html.
• Owners often think cats with chronic pain are showing normal aging signs.
• Signs of chronic pain are individualized based on location, but common signs include decreased grooming,
activity, and mobility.
• The chronic pain focus in the guidelines is on degenerative joint disease, because of its common occurrence
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49
in cats and dogs, and the lack of recognition and treatment of the condition in cats.
Interventions for Pain

Patient Considerations
• Animal personalities play an important roll in both the pharmaceutical and non-pharmaceutical treatments of
Generalist
pain. Some cats are just not amenable to being given oral medications in any form. Some cats will not
Combined
tolerate modalities like acupuncture.

• Comorbidities exist in some cats, making it important in the choice of medications.
• A prior sensitivity to a drug or class of drug makes it very important to get a thorough history.
Caregiver Considerations
• Always have a discussion with the cat’s owner and ask what their schedule is and their willingness to
administer medications on the schedule you have in mind.
• Can they be shown how to give a pill or liquid medications?
- Medicating cats is often difficult and frustrating for owners. Owner education on how to administer
medication should start early on if possible, with positive reinforcement and rewards being
the basis of training cats.
- Veterinary team members must have patience in educating and demonstrating medication
administration. Repeat demonstrations may be necessary.
Para-professional
- Medication options need to adequately relieve patient pain and as well as promoting client
compliance.
• Are they able to perform other treatments such as rehab exercises?
• What is their budget?
• Every aspect of their cat’s treatment and prognosis, explanations of medications and how to administer, and
any other special consideration for each case needs to be talked about before your client leaves.
Veterinary Considerations
• Always make a treatment plan with an outcome measure and discuss it with your client. This is the number
one reason behind treatment failures that I see sent to my referral practice.
• Set up at least the first recheck appointment before they leave the office.
• Don’t try to perform treatments or give medications that are outside of your comfort zone.
Pharmaceutical Interventions for Pain

Although there have been few advances in new medications available for treating pain in cats, there is a
better understanding of many off-label treatments. These off-label uses of medications include those that are
approved for use in cats in a different manner, and those that have only human approval. A discussion of those uses
follow.
Opioids
• Opioids have become more common with treating acute pain in cats
o Less fear of hyperthermia and other side effects
o FDA approved long-acting opioid Simbadol
Nonsteroidal Anti-inflammatory Drugs

• More research to support the use of both acute and chronic administration of NSAIDs
o Off label use in the U.S.
o Evidence to support use in cats with chronic renal disease (meloxicam).
• Can be used to treat any inflammatory source of pain
Local Anesthetics
• The only true Analgesics
Advanced
o Stops 100% of pain when given as a local. No other pain medication can make that claim
o The guidelines say to use local anesthetics in every case, insofar as possible
• Adverse events are rare
o Does not delay wound healing
o Damage to nerves is uncommon, less that one in 10,000
• Anesthetic Sparing
• Systemic Use
o Controversial use of Lidocaine as part of CRI
o “May” have negative cardiovascular effects
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50
Gabapentin
• Initially used as an anticonvulsant in humans
• Works by down regulating the calcium channels
• Acute use
o Perioperatively
Generalist
Combined
• Chronic use
o Neuropathic pain
o Maladaptive pain
Ketamine
• Mode of action
o NMDA receptor
 Responsible for hyperalgesia/allodynia
• Sub anesthetic doses provided as constant rate infusions
o Analgesia
o Anti-hyperalgesia
o Anti-allodynia
• Amantadine also blocks the NMDA receptor and although there are positive studies in dogs, it has not been
Para-professional
looked at in cats extensively enough to warrant use: safety and efficacy concerns
Tramadol
• Actually does work in cats…if you can ever get more than one dose down
• Converts it to opioid metabolite
o Horses also do this
o Dogs cannot
Maripotant
• Works by blocking Substance-P from the NK-1 receptor
• Only two good studies out there showing it has an analgesic effect similar to morphine for cat spays
o Is also a strong anti-emetic; some of its anti-pain effect may be due to that
 In one human study, most patients felt worse from the nausea compared to the pain
• Give it, but not in place of opioids, but in addition to them
o Great at stopping opioid-induced nausea
Non-pharmaceutical Considerations for Pain

Advances in non-pharmaceutical measures, and general acceptance (and even expectation) by the cat-
owning public of modalities such as acupuncture and physical rehabilitation makes it necessary for the veterinary
practitioner to consider these modalities in their pain treatments. To provide the best care possible, the practitioner
who cannot provide these services should be aware of other veterinarians to whom they can refer when appropriate.
The following is a discussion of these modalities and how they can fit into your practice.
Acupuncture
• Acupuncture can be used to modulate the pain experience for both acute and chronic pain cases
• Analgesia should not depend solely on acupuncture in acute pain cases, such as surgery
• Chronic pain provides many opportunities for acupuncture
o DJD
o Pancreatitis
o Renal disease
o Pelvic issues like Pandora syndrome
o Others
Advanced
Physical Rehabilitation
• Has mostly been the mainstay of dogs and horses…cats are finally getting paid attention to
• Most cats are willing recipients of rehab procedures
• Includes many modalities
o Exercise
o Underwater Treadmill
o Physical manipulations
o Laser
o PEMF Therapy
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51
o More
Myofascial Trigger Point Therapy
• The treatment of muscle pain
o Common sequel to other sources of pain such as DJD and surgery
o Sometimes more painful than the initiating cause
Generalist
Combined
• It involves the use of acupuncture needles or massage to release trigger points
Massage Therapy
• Classes are taught in medical massage
Weight Loss
• A weight loss of ten percent can provide the same pain relief as an NSAID
Exercise
• For strengthening of affected limbs and weight loss
Nutrition
• Joint mobility diets
Para-professional
Home Environment Modification

• Environmental changes are often necessary to allow the cat to continue to perform its normal behaviors. For
example, pet stamps to the bed or a bench to a favorite chair can allow the cat to reach favored areas and
be with family members when it wants to.
• Easy access to food, water, and litter boxes is also essential. Raising food and water dishes can allow cats
with DJD to sit comfortably while eating.
Nursing Care
• Keep the patient warm and comfortable, providing a safe, comfortable, and secure resting area that allows
9
the cat to feel hidden. Good examples are a cardboard box with soft bedding or an igloo-type cat bed.
• Caging should minimize stress, with cats separated from dogs and from seeing other cats. Feli-way use
increases security and familiarity.
• All of the cats’ needs, such as food, water, hygiene, toileting area, and a place to hide should be provided.
10
When appropriate (e.g., an awake and alert patient), a perch should be provided as well.
Handling
11,12
• Gentle handling is essential, especially for cats with either acute or chronic pain.
13
• Since DJD is common in both the axial and appendicular joints , scruffing or stretching out legs tightly can
11
exacerbate pain and should be avoided. There are many other handling techniques that are more effective
11,12,14
and safe.
• Jugular venipuncture with legs kept in a comfortable position and standing cystocentesis are more
comfortable sample collection methods in cats with DJD.
Feline Degenerative Joint Disease

• Degenerative joint disease (DJD) is a very common condition in cats that impacts quality of life and the
relationship owners have with their cats. However, it is frequently unrecognized and under-diagnosed. Most
cat owners consider the subtle behavior changes secondary to DJD to be normal aging changes.
• The signs of DJD pain in cats are subtle because of the cats’ tendency to hide pain as a protective
mechanism. Additionally, as opposed to the dog, most cats with DJD don’t limp because DJD is usually
13
bilateral. Signs are noted in Table 1.
• Radiographic evidence of DJD can be seen equally at all ages. In one study in which cats between 6
months and 20 years of age were randomly selected, 91% of the cats had radiographic evidence of DJD with
Advanced
13
equal frequency in all age groups. It is important to recognize that radiographic evidence does not equate
15
with pain, but the disease process can start in young cats. The pain burden increases with age.
• Axial DJD is more frequently found between thoracic vertebrae T7-T10, but the lumbar vertebrate are
16
affected more severely. Axial DJD increases with age. The more commonly affected appendicular joints are
the hips, elbows, knees, and hocks. As opposed to axial DJD, appendicular occurs equally through the
16
ages.
• A diagnosis of DJD is made by history that includes behavioral and lifestyle changes, examination, and
radiographs to rule out other conditions.
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2,17
• The mainstay of DJD treatment in cats is NSAID’s. Although approved for long-term use in cats in many
countries, they are not to date approved in the United States, and owners need to be made aware that the
use of this medication in cats is extra-label. Important considerations are dosing on lean body weight, client
educations about side effects and to contact the practice immediately and stop medication if vomiting or
anorexia, and follow-up including diagnostic testing.
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Combined
• Concurrent medical conditions are common in cats affected with DJD. In one study, 44% of cats with DJD
18
showed signs of concurrent conditions, especially chronic kidney disease. Low-dose meloxicam has been
19
used successfully in cats with both DJD and CKD as long as the cats are in have stable kidney disease.
• Other pharmacological treatments used concurrently or instead of NSAIDs in cats that cannot be treated with
them are available. Environmental management is an important supportive measure, providing easy access
to litter boxes, resting areas, and other favored spots.
Hospice and Palliative Care

Terminology
These terms are often used interchangeably, but mean two different things. Palliative care is the treatment
of pain. Hospice, may include palliative care, but with no intention of treating the underlying disease. I will be
referring only to hospice care.
Reasons for hospice care
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Owners may not wish to pursue treatment of a disease, especially a chronic disease or one that ends in death
• Money is sometimes the reason, but more often than not it isn’t the entire picture
• The change in the relationship with their cat that intensive chronic treatments sometimes demand; from
caregiver to caretaker
• Grave prognosis
• Social and religious beliefs
• Doesn’t believe in euthanasia
Hurdles in hospice care

• Pressure from friends, neighbors and even family members to euthanize
• Time it takes to care for ill animal
• Emotional toll
o Caretaker
o Veterinarian
Table 1. Behavioral Signs of DJD in cats

12
Adapted from Feline Behavioral Heath and Welfare
Changes in the normal behavior of that individual cat
• Appetite
- Decline
• Sleep/rest
- Increase sleep or restlessness
• Grooming
- Matting due to decreased grooming or overgrooming of the painful area
• Play
- Decreased
Advanced
• Toileting behavior
- Difficulty getting into litter box
- Change in position in box or toileting next to box
- Constipation
• Activity
- “Slowing down” or “getting old” – most common signs noticed by owners
- Jumping and height of jump
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- Going up and down stairs
• Mobility
- Stiff, may be only when rises
- Lameness – not common
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Combined
• Disposition or attitude
- Irritable: “Grouchy” or “grumpy”
- Clingy
• Interactions with people or other animals

- Withdrawn or avoid others
- Attention-seeking
- Irritable to aggressive with handling
• Body posture
- Hunched
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- Stiff
- Not curled up normally when sleeping
- Neck stretched out and head lowered
• Facial expression – fixed gaze, dilated pupils, squinted eyes if acute pain (flare-up)
• Vocalization
- More or less vocal
- Purring can occur even if painful
Behavior problems
• Inappropriate urination
• Inappropriate defecation
• Cat-to-human aggression
• Inter-cat aggression
References
In addition to the below references, an extensive reference list is also available in the AAHA and AAFP Pain
1. Taylor PM, Robertson A Pain management in cats: past, present and future. Part 1. The cat is unique, J Fel
Med & Surg, (2004) 6:313-320.
2. Sparkes AH, et al., ISFM and AAFP Consensus Guidelines: Long-term Use of NSAIDs in Cats, J Fel Med &
Surg, 2010 (12)521-538.
3. Robertson SA, Lascelles BDX, Long-Term Pain in Cats: How Much Do We Know about This Important
Welfare Issue? J Fel Med & Surg, 2010 (12) 188-189.
4. Benito J, Gruen ME, et al., Owner-assessed indices of quality of life in cats and the relationship to the
presence of degenerative joint disease, J Fel Med & Surg, 2012 (14) 863-870.
5. Lascelles BDX, et al. Evaluation of a digitally integrated accelerometer-based activity monitor for the
measurement of activity in cats, Vet Anaesth Analg, 2008 (35) 173-183.
6. Bennett D, Osteoarthritis in the Cat: 1. How common is it and how easy to recognize, J Fel Med & Surg,
2012, (14) 65-75.
7. Brondani JT, et al., Refinement and initial validation of a multidimensional composite scale for use in
Advanced
assessing acute postoperative pain in cats, Am J Vet Research, 72:2, 2011, 174-183.
8. Hellyer P, Rodan I, Brunt J, Downing R, Hagedorn JE, Robertson SA. AAHA/AAFP pain management
guidelines for dogs and cats. J Am Anim Hosp Assoc 2007; 43:235-248 and J Feline Med Surg 2007; 9:
466–80. Available at www.aahanet.org and www.catvets.com.
9. Carney HC, Little S, Brownlee-Tomasso D, et al. AAFP and ISFM feline-friendly nursing care guidelines. J
Fel Med Surg 2012;14(5):337–49
10. Ellis S, Rodan I, Carney HC, et al. AAFP and ISFM feline environmental needs guidelines. J Feline Med
Surg 2013;15(3):219–30.
11. Epstein M, Rodan, I, Griffenhagen G, et al. 2015 AAHA/AAFP pain management guidelines for dogs and
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cats. J Fel Med Surg. 2015;17:251–272.
12. Rodan I, Heath S, Handling the cat that is in pain, In: Rodan I, Heath S, ed. Feline Behavioral Health and
Welfare. St Louis: Elsevier; 2015: 281-299.
13. Lascelles BDX, Henry JB, et al, Cross-sectional study evaluating the presence of radiographic degenerative
joint disease in domesticated cats. Vet Surg, 2010: 39 (5): 535-544.
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14. Rodan I, Sundahl E, Carney H, et al. AAFP and ISFM feline friendly handling guidelines. J Feline Med Surg
2011; 13:364–375.
15. Bennett D, Morton C, A study of owner observed and behavioural lifestyle changes in cats with
musculoskeletal disease before and after analgesic therapy, J Fel Med & Surg, 2009, 11:997-1003
16. Lascelles D, Robertson S, DJD-Associated Pain in Cats: What can we do to promote patient comfort? J Fel
Med & Surg, (2010) 12, 200-212.
17. Gowan RA, Lingard AE, Johnston L, et al. Retrospective case-control study of the effects of long-term dosing
with meloxicam on renal function in aged cats with degenerative joint disease. J Feline Med Surg,
2011;13:752–761.
18. Marino CL, Lascelles BDX, Vaden SL, et al. Prevalence and classification of chronic kidney disease in cats
randomly selected from four age groups and in cats recruited for degenerative joint disease studies. J Feline
Med Surg. 2014;16:465–472.
19. Gowan RA, Baral RM, Lingard AE, et al. A retrospective analysis of the effects of meloxicam on the
longevity of aged cats with and without overt chronic kidney disease. J Feline Med Surg, 2012;14(12):876-
Para-professional
881.
NOTES:
Advanced
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Advanced Para-professional Combined
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Thoracic Ultrasound: Feline Thoracic Disease

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Introduction
Radiography remains a fundamental technique for thoracic imaging. However, in some situations, thoracic
ultrasound may prove a better alternative or complementary to radiology. Ultrasound is very useful in feline thoracic
medicine; it does not require sedation and is less stressful than radiology or computed tomography. Furthermore the
feline conformation is amenable to produce good quality thoracic ultrasound.
Technique
The thorax can be examined by using a subcostal, intercostal or a thoracic inlet window. When using a
1
subcostal window the thorax is imaged through the liver. To optimize this approach it is preferable to examine the
patient when the stomach is empty (12 hours fasting). Fasting is also indicated if sedation or general anesthesia is
needed (e.g. uncooperative patients or when biopsies are indicated).
Most cats are comfortable when examined standing, furthermore the standing position proves more
Para-professional
comfortable for most dyspneic cats. When using an intercostal window with the patient in sternal or standing position,
the thorax should be flexed away from the ultrasonographer in order to increase the space between the ribs (graphic
and photo 1). Flexion of the trunk in the direction of the ultrasonographer should be avoided as by doing so the
intercostal space is reduced. A sternal position is recommended in case of small volume pleural fluid as the fluid
Track A
collects ventrally and can be sampled under ultrasound-guidance.
Graphic and photo 1. The drawing shows increased space between the ribs when the thorax is flexed away from the
ultrasonographer. The photo shows how the patient is held in the standing position during ultrasound of the thorax.
Sector probes are often used for the thorax as they have a small footprint and they can easily fit into the
intercostal spaces. Sector mechanical probes are less convenient as they do not display the close ultrasound field;
these are now obsolete. Linear probes are used to visualize superficial structures (e.g. pleura); they provide excellent
detail but have the disadvantage of a large footprint so it is difficult to avoid the acoustic shadow artifact caused by
the ribs.
Trans-esophageal ultrasound may be used to investigate the mediastinum, the caudal lung lobes and the
tracheobronchial lymph nodes; however this technique requires anesthesia and highly specialized equipment that is
Advanced
not frequently available.
Ultrasound of the pleura, mediastinum and diaphragm

Pleural effusion is a common cause of dyspnea in cats. The list of common causes of a moderate to large
2
pleural effusion in cats is relatively short (see table 1). Thoracic ultrasound offers a fast and definitive diagnosis in
patients with suspected pleural effusion. Therefore ultrasound should be considered as the first modality to use in
dyspneic cats. Furthermore, ultrasound is more sensitive than radiography to detect small volume pleural effusion.
The echogenicity of the pleural fluid may give an idea of the nature of the fluid; transudate, modified transudate and
chylothorax are anechoic or hypoechoic whereas pyothorax and hemothorax are generally hyperechoic. In presence
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of pleural effusion, thoracic ultrasound can be very helpful to visualize thoracic lesions (parietal, pleural, pulmonary or
mediastinal), whereas, on radiographs, the presence of pleural effusion may obscure these lesions. In case of
localized pyothorax, thoracic radiographs may be helpful to guide the ultrasonographic examination.
Table 1: Common thoracic imaging findings

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Imaging finding Common underlying disease

Pleural effusion Cardiac failure
FIP
Thoracic neoplasia (e.g. mediastinal, pulmonary)
Pyothorax
Chylothorax
Mediastinal mass Lymphoma
Thymoma
Mediastinal cyst
Pulmonary mass Bronchogenic carcinoma
Granuloma
Thoracic ultrasound is an excellent method to check for presence of a mediastinal mass, particularly in
Para-professional
patients with pleural effusion. Mediastinal masses are frequently neoplastic, with some exceptions (e.g. mediastinal
cysts). Mediastinal cysts are easily recognized on ultrasound as they are round or oval, with well-defined margins,
thin walls and anechoic content (figure 1).
Track A
Figure 2: Ultrasound image of the cranial thorax of a cat, showing a round anechoic structure, compatible with a mediastinal cyst
(confirmed on FNA).
3
Biopsies are often required to reach a final diagnosis. Ultrasound guided biopsies (fine needle aspirate or
tissue core biopsies) should be performed with the patient under general anesthesia or heavy sedation to allow a
level of control over the patient and the lung movement. Possible complications are: pneumothorax, hemorrhage and
pyothorax.
The trans-hepatic approach (subcostal window) should be used in cases of caudal mediastinal or caudal
pulmonary lesions in contact with the diaphragm, diaphragmatic rupture, and pleuroperitoneal or peritoneopericardial
hernia.
Advanced
Peritoneopericardial diaphragmatic hernia is easily identified by the presence of abdominal organs in the
peritoneal sac (surrounding the heart) and can be seen also by using the standard cardiac windows. When using a
trans-hepatic approach, mirror image artifact should not be misinterpreted as a diaphragmatic rupture. The mirror
image artifact is recognized by the complete symmetry of the liver vasculature (and sometimes gallbladder) in each
side of the diaphragm.
Thoracic wall masses secondary to primary rib tumors in cats are uncommon. Metastatic lesions causing
osteolysis of the ribs have been described in cats with pulmonary carcinoma.
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Ultrasound of the lung
The ultrasonographic appearance of normal lung is mostly composed of artifacts. The reflection coefficient of
an interface is dependent on the difference of acoustic impedance of the two elements on the sides of the interface.
In the case of an air-soft tissue interface, the reflection coefficient is very large. Therefore, when ultrasound reaches
a normally aerated pulmonary field nearly all the sound is reflected back to the transducer, creating a reverberation
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artifact. With an intercostal approach, the thoracic wall is imaged until a hyperechoic line; this line is called pleural
line and is the interface between the soft tissue of the chest wall and the aerated lung. A series of horizontal lines,
parallel to the pleural line are seen in the deeper region of the field of view; these are called “A-lines” and represent
reverberation artifacts. The distance between A-lines is equal to, or a multiple of, the distance between the skin and
the pleural line. In the normal lung the pleural line moves synchronously with respiration: this dynamic horizontal
movement is called lung sliding.
It is not possible to visualize structures positioned behind aerated lung. In case of pulmonary atelectasis,
pulmonary consolidation and/or pulmonary masses there is little or no air in the lungs; therefore, when these lesions
are in contact with the thoracic wall or with the diaphragm, they can be visualized.
In case of suspected pulmonary disease, the suggested imaging technique to start with is radiography.
Radiographs offer an overview of the thorax and are used to determine whether there are any lesions that can
possibly be visualized by ultrasound. Although primary lung tumors are a relatively uncommon finding in cats, the
reported incidence may be increasing. Pulmonary tumors appear most commonly as a pulmonary mass and most
4
are located in the caudal lung lobes. When the pulmonary mass is in contact with the thoracic wall, it can be imaged
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with ultrasound. Pulmonary masses may cause lung lobe deformity and bronchial deviation or compression.
Pulmonary neoplasia can be either homogeneous or heterogeneous on ultrasound; the heterogeneous appearance
is often due to the presence of dystrophic mineralization and fibrosis (hyperechoic areas) or hemorrhage and
Track A
necrosis (hypoechoic). It is difficult to determine whether a pulmonary mass is of neoplastic or inflammatory origin,
therefore ultrasound may be used to obtain fine needle aspiration or tissue core biopsy of the pulmonary lesions.
When a mass is not in contact with the thoracic wall, CT guided biopsies should be considered as an alternative to
ultrasound guided biopsies.
Pulmonary atelectasis is often identified in presence of pleural effusion. In cases of complete atelectasis the
lung lobe appears triangular (sail shaped) and of fairly homogeneous echogenicity (figure 2). It is generally seen
floating within the pleural fluid. In cases of partial atelectasis (tip of the lung lobe) the collapsed part is smaller than,
and moving in synchrony with, the aerated part of the lung. It may be difficult to distinguish atelectasis from
pulmonary consolidation with ultrasound.
Figure 2: Ultrasound image of the thorax of a cat showing pleural fluid (PF), atelectasis of the tip of the lung lobe (arrow) and
aerated lung (asterisk).
Advanced
In case of pulmonary consolidation cells or fluid replaces air. The volume of the lung is therefore maintained
and not reduced like it is in case of atelectasis. When cells or fluid fill the bronchial lumen, the bronchus may be
confused with a pulmonary vessel (even though the bronchial walls are generally more echoic than the walls of a
vessel). The absence of Doppler signal can be used to help differentiate it from a vessel.
In collapsed and consolidated lung lobes it is generally possible to identify residual air within the bronchi that appear
as hyperechoic branching linear structures. Residual air produces reverberation artifacts and can move within the
bronchus during the respiration phases.
In cases of lung lobe torsion the lung lobe volume is reduced, maintained or increased, the direction of the
lobar vessels and bronchi is unchanged and generally there is absent or reduced Doppler signal from the vessels.
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In case of pneumothorax the normal sliding movement of the pleural line is lost; pneumothorax may be more
readily identified on thoracic radiographs.
Lung ultrasound is currently used in human patients to diagnose pulmonary edema. In patients with
pulmonary edema the normal ultrasonographic appearance of a pleural line with A-lines is lost. The ultrasonographic
appearance of pulmonary edema is characterized by the presence of artefacts called “B-Lines” (also called comet-
Generalist
tail, ring-down, or lung rockets artifacts), these artifacts are perpendicular to the pleural line and cause disruption of
5
the A-lines. Studies on the use of ultrasound to detect pulmonary edema in cats have not been published yet.
References
rd
1. Neelis DA, Mattoon JS, Nyland TG. Chapter 7: Thorax. Small Animal Diagnostic Ultrasound 3 edition.
Saunders 2015.
2. Beatty J, Barrs V. Pleural effusion in the cat: a practical approach to determining aetiology. J Feline Med
Surg 12: 693 2010
3. Reichle JK, Wisner ER. Non-cardiac thoracic ultrasound in 75 feline and canine patients. Vet Rad
Ultrasound; 41(2):154-162 2000
4. Aarsvold S, Reetz JA, Reichle JK et al. Computed tomographic findings in 57 cats with primary pulmonary
neoplasia. Vet Radiol Ultrasound 56(3): 272 2015
5. Gargani L, Volpicelli G. How I do it: lung ultrasound. Cardiovasc Ultrasound 4:12 2014.
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NOTES:
Track A
Advanced
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Ultrasound: Feline Gastrointestinal, Hepatic, and Pancreatic Diseases

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Introduction
In the past 10 years there have been great advances in imaging technology; the ultrasound equipment has
become better performing and more affordable. Ultrasound is an essential tool in the investigation of feline abdominal
disease.
Gastrointestinal Tract
Ultrasound is an excellent method for diagnosing small intestinal foreign bodies and to differentiate between
mechanical and functional ileus. When available, it has eliminated the need for gastrointestinal contrast radiography.
Intestinal dilatation is a useful indicator for presence of small intestinal obstruction; when observed, a detailed
accurate search for a possible cause of obstruction should be undertaken. Ultrasound is particularly useful to exclude
1
the presence of an obstructive process. Foreign bodies on ultrasound are characterized by variable degrees of distal
acoustic shadow and surface reflection; both are dependent on the nature of the material. It is important to consider
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that some foreign bodies are not very reflective and do not cause a strong acoustic shadow as they may have
ultrasound propagation characteristics similar to soft tissue (Figure 1).
Track A
Figure 1: Ultrasound image of a small intestinal foreign body in a cat. Note the absence of acoustic shadow.
Radiographic diagnosis of intestinal foreign body is challenging when the FB in not visible and is not causing
obvious intestinal distension. Lack of intestinal dilatation may be due to partial obstruction, recent obstruction or
duodenal obstruction. In many cases of duodenal obstruction, the duodenum is dilated but is filled only with soft
tissue density (no gas) therefore the dilated loop is not clearly identified on the radiographs. In case of duodenal
obstruction the chances to confidently diagnose obstruction on the basis of radiography alone are decreased (except
when the FB is seen). Linear foreign bodies are readily identified in ultrasound and present with a typical plicated
appearance of the intestine with or without ultrasonographically visible intraluminal foreign body (Figure 2).
Advanced
Figure 2: Ultrasound image of a linear foreign body in a cat. Arrow heads show the linear foreign body, the arrow shows intestinal
plication.
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Intestinal intussusception can usually be easily diagnosed on ultrasound; whereby a portion of bowel can be
visualized telescoping into adjacent bowel. The resultant typical appearance is of multiple concentric layers when
viewed in transverse section. Intussusception in cats is more frequently associated with an underlyigng intestinal
neoplasia compared to dogs, which seem more likely to have an underlying inflammatory disease.
Inflammatory diseases of the small intestine are not always depicted by ultrasound.Ultrasonographic signs of
Generalist
inflammatory bowel disease include; poor intestinal wall layer definition, focal thickening and large hypoechoic
mesenteric lymph nodes; but in some cats no abnormalities are found. A hyperechoic line within the mucosa has
been associated with fibrosis in cats with chronic inflammatory disease; however this ultrasonographic finding is non-
2
specific as it can be found also in cats without gastrointestinal disease.
The intestine of cats with low-grade alimentary lymphoma (lymphocytic lymphoma) may have normal
ultrasonographic appearance and, usually, is indistinguishable from the intestine of cats with inflammatory bowel
disease. Ultrasonographic findings of low-grade lymphoma include increased thickness of the intestinal wall with
preservation of the intestinal layers and mesenteric lymphadenopathy. Occasionally focal lesions have been reported
3
with low-grade alimentary lymphoma. High-grade alimentary lymphoma typically results in segmental mural
thickening with loss of layers (Figure 3).
Para-professional
Track A
Figure 3: Ultrasound image of small intestinal lymphoma. There is focal mild mural thickening with loss of layering appearance
and hypoechogenicity (asterisk). The arrow points at the level where the subcutaneous layer is interrupted.
Lymphoma lesions are often concentric whereas lesions due to mast cell tumors and adenocarcinoma are
often eccentric; due to overlapping findings symmetry cannot be used to distinguish between different kinds of
tumors. According to recent literature thickening of the muscularis propria seems to be more often seen in cats with
4
lymphoma or inflammatory bowel disease than in cats with normal small intestine. Having been reported also in cats
with eosinophilic enteritis, this sign alone cannot be reliably used to make a final diagnosis and a differential list
should be formulated. Trans-mural or mucosal gastrointestinal masses, commonly pyloric or at the ileocolic junction,
are reported in case of feline gastrointestinal eosinophilic sclerosing fibroplasia.
Fungal infections in endemic regions and granulomatous lesions are difficult to differentiate from neoplastic
lesions. In cats, ultrasound enables good examination of the ileocolic junction. A recent article evocate the possibility
of underdiagnosed feline typhlitis on the basis of some ultrasonographic findings observed at the ileocolic junction in
5
cats with gastrointestinal signs and in absence of other gastrointestinal ultrasonographic findings. The
ultrasonographic findings observed were: thickened ileocolic junction, enlarged cecal lymph nodes and focal
mesenteric hyperechogenicity at the ileocolic junction. Fine needle aspirate of the lesions were non-diagnostic,
therefore a final diagnosis could not be reached.
Regional lymph nodes are always investigated during the abdominal ultrasound. Round, enlarged and
hypoechoic lymph nodes are more likely metastatic. Inflammatory lymph nodes can be enlarged but generally they
maintain their normal shape. Necrosis and hemorrhage can cause lymph-nodal mixed echogenicity and irregular
outline.
Pancreas and Liver

Advanced
Feline pancreatitis has been recognized as a significant disease only in recent years. Ultrasonography is not
a very sensitive diagnostic tool for pancreatitis in cats (11-35%), but it is very specific once changes are present.
Typical ultrasonographic findings of pancreatitis are an enlarged hypoechoic pancreas, with or without cavitary
lesions, surrounded by hyperechoic mesenteric fat. Associated findings may be dilatation of the common bile duct
and peritoneal fluid (sometimes only localized in the pancreatic region). No association has been found between
pancreatitis and size of the pancreatic duct.
When measuring the common bile duct, it should be taken into consideration that a great variability of
common bile duct size has been described in cats, with a normal upper limit size at 4mm. In most cats with
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cholangitis the liver and biliary system appears normal on ultrasound examination. Signs associated with cholangitis
include hyperechoic liver parenchyma, hyperechoic gallbladder content, and increased pancreatic size.
In case of extrahepatic biliary obstruction, ultrasound is an efficient tool to visualize an obstructive calculus
(Figure 4). However, according to literature, ultrasound was not able to differentiate between extrahepatic
6
obstructions due to neoplastic versus inflammatory cause. Gall bladder dilatation was visible in less than 50% of the
Generalist
obstructed cases.
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Track A
Figure 4: Ultrasound image of a cat with a calculus at the duodenal papilla (asterisk). The arrow points at the duodenum. The liver
(L) and pancreas (P) are normal.
Gall bladder sludge was reported as an uncommon finding in cats that underwent abdominal
ultrasonography for investigation of a variety of disease (prevalence of 14%) and was associated with increased
7
alanine aminotransferase and total bilirubin. Cats with gall bladder sludge were significantly older and lighter than
the rest of cats examined. In humans this finding has been associated with various hepatic and gastrointestinal
diseases, in dogs only a non-significant trend (of association) was found.
An association between feline IBD, pancreatitis and hepatic disease (also called feline triaditis) has been
described however it is difficult to prove due to the limitation of the diagnostic test available for these diseases.
Clinical signs, and clinicopathological and ultrasonographic abnormalities lack precision for hepatic and pancreatic
histopathological lesions in cats with alimentary signs, and cannot reliably predict from which organs biopsies should
8
be collected. Reaching a final diagnosis of triaditis is often challenging on ultrasound; histopathological examination
of tissue samples is considered the gold standard for diagnosis of this disease.
Contrast enhanced harmonic ultrasound has been used to improve detection and to attempt classification of
hepatic lesions in dogs. This technique requires specific equipment capabilities and, for the moment, its use is limited
to some private and academic centers involved in clinical research studies on the subject.
Computed tomography has been used to evaluate feline hepatic lipidosis. It has been shown that CT
measures of X-ray attenuation in the liver may not be accurate predictors of naturally occurring hepatic lipidosis in
9
cats. Compared to ultrasound, contrast computed tomography has the inconvenience of requiring general
anesthesia; therefore is not the first imaging technique of choice to investigate severely ill patients. In cats, high-
resolution transducers offer excellent visualization of the gastrointestinal tract, pancreas, liver and biliary tract;
furthermore the veterinary literature provides more extensive information about the use of ultrasound for feline
gastrointestinal, hepatic and pancreatic disease than CT.
References
1. Garcia DAA, Froes TR, Vilani RGDOC et al. Ultrasonography of small intestinal obstructions: a contemporary
approach. J Small Anim Pract 52(9): 484-490 2011
2. Gaschen L. Ultrasonography of small intestinal inflammatory and neoplastic diseases in dogs and cats. Vet
Clin North Am Small Anim Pract 41(2): 329-344 2011
3. Russell KJ, Beatty JA, Dhand N, et al. Feline low-grade alimentary lymphoma: how common is it? J Feline
Advanced
Med Surg 14(12):910 2012

4. Daniaux LA, Laurenson MP, Marks SL et al. Ultrasonographic thickening of the muscularis propria in feline
small intestinal small cell T-cell lymphoma and inflammatory bowel disease. J Feline Med Surg 16(2):89
2014
5. Taeymans O, Holt N, Penninck DG, Webster CR. Ultrasonographic characterization of feline ileocecocolic
abnormalities. Ver Radiol & Ultrasound 52(3): 335-339 2011
6. Gaillot HA, Penninck DG, Webster CRL et al. Ultrasonographic features of extrahepatic biliary obstruction in
30 cats. Vet Radiol & Ultrasound 48(5); 439-447 2007
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7. Harran N, d’Anjou MA, Dunn M et al. Gallbladder sludge on ultrasound is predictive of increased liver
enzymes and total bilirubin in cats. Canadian Veterinary Journal 52:999-1003 2011
8. Freiche V, Faucher MR, German AJ. Can clinical signs, clinicopathological findings and abdominal
ultrasonography predict the site of histopathological abnormalities of the alimentary tract in cats? J Feline
Med Surg [Epub ahead of print] 26 Feb 2015.
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9. Lam R, Niessen SJ, Lamb CR. X-ray attenuation of the liver and kidney in cats considered at varying risk of
hepatic lipidosis. Vet Radiol Ultasound 55:141 2014
NOTES:
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Imaging: Feline Urinary Tract Disease

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Introduction
High resolution ultrasound has changed our approach to investigation of the urinary tract disease. Survey
radiographs provide in most of the cases very limited useful information; furthermore whilst contrast radiography
requires general anesthesia, ultrasonography allows a rapid, non-invasive assessment of the urinary tract in a
conscious patient.
Upper Urinary Tract

Ultrasonography is an excellent modality to image the feline kidneys. Renal ultrasound in cats is less
technically challenging than in dogs (subcostal position of the right kidney in deep chested dogs) and the kidneys are
positioned relatively close to the skin therefore the use of a high resolution linear transducer is possible. Ultrasound
enables good differentiation between different kinds of focal renal lesions (e.g. cyst versus nodule) and with improved
quality of the ultrasound equipment, it is now possible to visualize also very small structures (e.g. normal ureters) and
Para-professional
small changes (e.g. dilatation of the renal pelvis of less than 1 mm).
Minimal to mild dilatation of the renal pelvis may be observed in a number of cats with clinically normal renal
function (figure 1). Mild to moderate dilatation of the renal pelvis has been associated with increased diuresis (e.g.
secondary to intravenous fluid administration, diuretics administration), pyelonephritis, outflow obstruction and
Track A
chronic parenchymal renal disease. In a recent study it was attempted to determine whether it is possible to predict
the underlying cause of renal pelvis dilatation on the basis of the size of the renal pelvis dilatation measured on
ultrasound. Dogs and cats with hydronephrosis were divided in 6 groups: clinically normal renal function, normal
renal function with diuresis, pyelonephritis, acute or chronic renal insufficiency, obstructive disorders and a
miscellaneous group. The conclusion was that a pelvic width of more than 13mm was always associated with
obstruction. Renal pelvis width in ten cats with clinically normal renal function was between 0.8 and 3.2 mm. In case
1
of renal pelvis width of less than 13mm, it was not possible to differentiate between the groups.
Figure 1: Ultrasound image of the left kidney of a cat with mild dilatation of the renal pelvis.
Urolithiasis is a common and often recurrent disease in cats. Both ultrasound and contrast radiography are
useful in the diagnosis of this disease. Ureteral obstruction can be challenging to diagnose and difficult to treat.
Lateral, ventrodorsal and if necessary oblique view of the abdomen might be acquired in an attempt to visualize
Advanced
urinary calculi on survey radiographs. An enema may be given if faeces are superimposed on the area of interest.
Radiography may be useful to quickly show size, position and number of the calculi when these are radiopaque.
However not all ureteral obstructions are caused by radiopaque calculi and not all mineral opacities seen
radiographically represent obstructing calculi. Ureteral strictures, radiolucent calculi and ureteral plugs are not visible
on survey radiographs.
Urinary calculi are seen as hyperechoic structures causing acoustic shadow on ultrasound, however small
calculi may not cause an acoustic shadow. Ureteral plugs may be seen as material isoechoic to the ureteral lining. In
case of dilated renal pelvis an attempt to follow a dilated ureter until a possible obstruction should be made (figure 2).
2
Occasionally the ureteral dilatation might not extend until a visible cause of obstruction. In some cases the calculus
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could have been dislodged or the cause of obstruction could not be apparent. Hyperechoic peri-ureteral tissue may
3
be detected associated with ureteral strictures.
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Para-professional
Figure 2. Ultrasound image of a cat with left hydronephrosis (arrow) and two left ureteral calculi (between calipers).
In the presence of hydronephrosis, when the cause of obstruction is not readily identified, an ultrasound-
guided antegrade pyelogram should be performed. Antegrade pyelography helps determining whether there is partial
Track A
or complete obstruction (figure 3). The study should be performed with the patient anaesthetized. The area over the
kidney is clipped and aseptically prepared. The renal pelvis dilatation is measured and the safest path for insertion of
the needle is selected with ultrasound. Under ultrasound guidance a hypodermic needle (23 gauge needle – 1 inch)
connected to a small extension set and 3 way-taps is inserted into the renal pelvis. If possible urine is collected from
the dilated renal pelvis before injection of contrast. The contrast injected is equal to 75%-100% of the urine volume
removed. Lateral and ventrodorsal abdominal radiographs (or fluoroscopic images) should be obtained immediately,
4
at 5 minutes and possibly at 15 minutes post-injection. This technique is also extremely useful to detect possible
ureteral tears.
Advanced
Figure 3. VD and lateral abdominal radiographs post contrast (antegrade pyelogram) showing complete obstruction
of the right ureter. The arrow on the DV view shows leakage of contrast post-injection (not to confuse with ureteral
tear). The arrow on the lateral view shows the ureteral obstruction.
In case of ureteral obstruction, intravenous urography is often not particularly useful because of the lack of
contrast excretion secondary to renal failure. The same problem can happen when performing computed tomography
with intravenous administration of contrast. Computed tomography (CT) may demonstrate additional calculi not
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detected by radiography or ultrasound. Compared to ultrasound, intravenous urography is a more reliable method to
investigate the presence of ectopic ureter.
5
Renal lymphoma is the most common renal neoplasm of cats, other tumors occur less frequently.
Lymphoma often results in bilateral diffuse increase in cortical echogenicity, usually in combination with diffuse renal
enlargement. It may cause distortion of the renal contour. The ultrasonographic finding of a renal hypoechoic
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subcapsular area, often of crescent shape, is associated with lymphosarcoma infiltrate. This sign has a specificity of
85% for diagnosis of renal lymphosarcoma; however a similar finding can also be found in case of renal carcinoma,
6
undifferentiated malignant neoplasia and chronic active nephritis. A hypoechoic subcapsular rim has also been
reported with feline infectious peritonitis. It is sometimes difficult to differentiate between subcapsular effusion and
subcapsular infiltrate as both appear hypoechoic on ultrasound. A fine needle aspirate of the lesion can be helpful to
differentiate between the two. In case of lymphosarcoma, performing a fine needle aspirate of the lesion is often of
diagnostic value. Primary renal tumours in cats are typically unilateral and include carcinomas (adenocarcinoma and
7
transitional cell carcinoma), adenoma, hemangiosarcoma and nephroblastoma.
In most of the cases renal lesions are visible, except for isoechoic lesions that blend with the surrounding
parenchyma. Contrast harmonic ultrasound has been used in an attempt to characterize the appearance of focal
renal lesions; further studies are necessary to demonstrate the usefulness of this technique in a clinical setting and
justify the expenditure due to acquire the equipment necessary to perform contrast studies.
Lower Urinary Tract
Para-professional
Nowadays ultrasound equipment is readily available in most small animal practices, therefore regardless of
whether you work in a small animal practice or in a large referral hospital survey radiographs are no longer the first
step used in the evaluation of patients with lower urinary tract disease. Ultrasound is probably the most commonly
Track A
used imaging modality to examine the urinary bladder.
On ultrasound, the urinary bladder normally appears as a rounded anechoic structure with a thin wall.
Adequate assessment of the bladder is not possible when empty, or after negative contrast cystography. The normal
bladder wall is approximately 1-2 mm thick and has a faintly layered appearance (when observed with a high
resolution transducer). In a normal empty bladder the cranioventral aspect of the wall always appears thicker than
the caudal area. The ureterovesical junction may be seen as a small focal thickening of the bladder wall. If the
urinary bladder is empty it is necessary to repeat the ultrasound later on, when the bladder is full.
Localized thickening of the bladder can occur with cystitis or neoplasia. The typical location for changes
associated with cystitis is the cranioventral bladder wall. Calculi and blood clots are often associated with cystitis.
With the patient in lateral recumbence, it is recommended to look down from the uppermost side of the urinary
bladder; this will ensure visualization of calculi and blood clots located in the recumbent aspect of the urinary bladder.
Scanning the urinary bladder in both sagittal and transverse planes is recommended. Calculi typically have a hyper-
reflective surface with distal acoustic shadowing. Blood clots have an irregular shape and often a “tail”.
Feline urinary bladder cancer is rare. The most commonly reported is transitional cell carcinoma (TCC, figure
4). In cats TCC more frequently affects males. Historically we are taught that the most common site of urinary
bladder tumors is the trigone area, however this applies only to dogs. In a recent report in cats, 55% of the TCC
were involving the bladder wall distant from the trigone and 45% were involving the trigone. And at initial evaluation
8
only 15% had complete urinary obstruction.
Advanced
Figure 4. Ultrasound image of the urinary bladder of a cat with focal thickening of the bladder neck (between calipers), the patient
was diagnosed with TCC.
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Urinary bladder lymphoma is rare and from the limited number of reports it is not possible to say if it has a
predilection site. Its ultrasonographic and radiographic appearance is similar to those of other urinary bladder tumors.
Hydronephrosis and hydroureter seem to be common complications associated with urinary bladder lymphoma;
however they are non-specific for lymphoma. Looking for signs of ureteral obstruction and visualization of the
regional lymph nodes are essential parts of the ultrasound exam when a urinary bladder mass is found. In case of
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9
urinary lymphoma other abdominal organs may be found to be affected by the tumor.
Biopsies of a urinary bladder mass taken via trans-abdominal fine needle aspirate (FNA) are generally
discouraged because the mass could potentially be a TCC and TCC may seed along the needle tract. Diagnosis of
TCC is generally made via traumatic catheterization or via urinary sediment examination. However these methods
may fail to identify other kind of tumors (e.g. lymphoma, leiomyoma) that may require trans-abdominal FNA, surgical
biopsies or in female cats cystoscopic biopsy. Transabdominal FNA should be considered when urinary bladder
catheterization repetitively fails to give an answer or when the mass is so big that the prognosis, if it was TTC, would
be poor regardless of the potential seeding of the tumor along the needle tract.
When ultrasound is not available the urinary bladder can be imaged via contrast radiography. Double
contrast cystography is a good way of visualizing both intraluminal structures (e.g. calculi or blood clots) and mural
lesions. Survey radiograph and collection of urine must be obtained before starting the contrast study. Survey
radiographs should be checked carefully before starting the study as they may contain diagnostic findings. An enema
may sometimes be necessary. Intraluminal structures appear as contrast filling defects with double contrast
cystography studies. A filling defect is anything that alters the normal contrast filling of an area by occupying space
Para-professional
that should normally be occupied by contrast. In order to obtain a good quality double contrast study, a small amount
of positive contrast (1-2 ml) should be deposited via a catheter into the empty bladder and the patient should be
rolled over to ensure adequate coating of the bladder; then, to complete the double contrast study, negative contrast
Track A
should be inserted in the urinary bladder. In cats with cystitis the urinary bladder can be particularly inelastic and may
accommodate only a small amount of contrast. Therefore to avoid over-distension and rupture of the urinary bladder
it is recommended to palpate the urinary bladder during the injection of contrast rather than injecting a predetermined
volume of contrast. To reduce straining it is also recommended to administer 2-3 ml of 2% lidocaine. Contrast studies
are normal in 85% of cats with feline idiopathic cystitis; focal or diffuse thickening of the bladder wall, and contrast
agent dissecting through the bladder wall, may be seen in some cases.
Retrograde positive contrast urethrocystogram is preferred over ultrasound to investigate lower urinary tract
rupture (figure 5), urethral lesions or anatomical abnormalities (e.g. urachal abnormalities, ectopic ureter).
Radiographs must be taken while injecting the contrast; this enables visualization of the urethra when it is distended
by the contrast. When urinary tract rupture is suspected, negative contrast (pneumocystogram) should not be used
as it may lead to gas embolization into the circulatory system and sudden death. A pneumocystogram is helpful
before an intravenous urogram when searching for ectopic ureters as it enables better visualization of the ureteral
arrival.
Advanced
Figure 5. Lateral abdominal radiograph post contrast (retrograde urethrocystogram) showing leakage of contrast from the cranial
aspect of the urinary bladder (arrow), consistent with urinary bladder rupture.
In case of urinary bladder tumors, regardless of the imaging technique used, to accurately track response to
therapy, it is important to follow a consistent protocol from visit to visit for bladder distension and patient positioning.
In addition, when using ultrasonography to monitor therapy response, it is critical to have the same operator perform
the examinations over multiple visits.
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References
1. D’Anjou MA, Bedard A, Dunn ME. Clinical significance of renal pelvis dilatation on ultrasound in dogs and
cats. Vet Radiol & Ultrasound 52(1): 88-94 2011
2. Kyles AE, Hardie EM, Wooden BG et al. Clinical, clinicopathologic, radiographic, and ultrasonographic
abnormalities in cats with ureteral calculi: 163 cases (1984-2002). J Am Vet Med Assoc 2005; 226(6): 932-
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3. Berent AC. Ureteral obstructions in dogs and cats: a review of traditional and new interventional diagnostic
and therapeutic options. Journal of Veterinary Emergency and Critical Care 2011; 21(2): 86-103
4. Kulendra NJ, Syme H, Benigni L et al. Feline double pigtail ureteric stents for management of ureteric
obstruction: short- and long-term follow-up of 26 cats. J Feline Med Surg 16(12):985 2014
5. Knapp DW Chapter 28: Tumors of the urinary system. In Withrow and MacEwen’s Small Animal Clinical
th
Oncology 4 Edition Saunders Elsevier 2007.
6. Valdes-Martinez A, Cianciolo R, Mai W. Association between renal hypoechoic subcapsular thickening and
lymphosarcoma in cats. Vet Radiol & Ultrasound 2007; 48(4): 357-360
7. Henry CJ, Turnquist SE, Smith A, et al. Primary renal tumours in cats: 19 cases (1992–1998). J Feline Med
Surg 1999; 1: 165–170.
8. Wilson HM, Chun R, Larson VS, et al. Clinical signs, treatments, and outcome in cats with transitional cell
carcinoma of the urinary bladder: 20 cases (1990-2004). J Am Vet Med Assoc 2007; 231: 101-106
9. Benigni L, Lamb CR, Corzo-Menendez N, et al. Lymphoma affecting the urinary bladder in three dogs and a
Para-professional
cat. Vet Radiol & Ultrasound 2006; 47(6): 592-596
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Dental Radiography Updates

Generalist
Exposing the Radiograph
Dental radiograph machines have a hand held switch to expose the radiograph. If it is possible, leave the
room prior to exposing the radiograph. If not, stand at least 6 feet away at a 90 to 135 degree angle to the primary
beam (meaning to the side or back of the tube head, not in front or behind). Once everything is set, press the button.
It is important to remember, that these switches are “dead man’s”. This means if you let up during the exposure, it
will stop the production of x-ray beams. On a standard unit, this will make a light radiograph, on a computer
controlled one it will give an error message and you will need to start over. Make sure you hold the button down until
the machine stops beeping.
Techniques for Individual Teeth

Mandibular Premolars and Molars
Depending on the patient, radiographs of the mandibular premolars and molars are the simplest veterinary
Para-professional
dental radiograph. They are made using the parallel radiographic technique. The patient is placed in lateral
recumbancy with the teeth to be imaged facing up. The film is placed parallel to the teeth on the lingual surface of
the teeth/mandible. The tube head should be positioned perpendicular to both the teeth and the film.
Track A
Tip for Imaging the Mandibular P3S
However, in feline patients, there is commonly a problem in imaging the apices of the third premolar
(especially the mesial root) due to the interference of the mandibular symphysis. A standard parallel view will not
image these apices. To image the entire arcade, the bisecting angle often must be utilized. To use this technique,
the film is placed in the patient’s mouth at approximately a 90 degree angle to the tooth roots so that the lingual edge
of the film is touching the opposite mandible. The beam is then placed perpendicular to the angle between the tooth
roots and the film which is approximately 45 degrees. Note that there may be slight elongation to this view which is a
fair tradeoff for viewing the apices. A combination of the above two views is ideal in these patients as the fourth
premolar and first molar are most accurately depicted in the former view and the third premolar fully imaged (if
slightly elongated) on the latter.
Mandibular Incisors and Canines

All of the mandibular incisors and both mandibular cuspids are able to be taken on the same film in feline
patients. In rare cases, there may be a significant difference in the radiographic exposure required between the
incisors and cuspids; however in these cases only a change in the setting rather than positioning is necessary. The
angle used is a slight modification of the bisecting angle technique. It is important to remember that the roots of these
teeth curve caudally to almost a 45 degree angle in many cases. This means that the roots and the crowns have
substantially different angles. Generally it is more important to image the roots as opposed to the crowns. Therefore,
the angle of the ROOT, not the crown, is utilized for the bisecting angle calculation. This makes the technique much
closer to parallel than if you were imaging the crowns only.
The other important point to consider when imaging canine teeth is their relative length. These are quite
long; however with the small patient size they can still be imaged on the same film as the incisors with a size 2
sensor. This author will place the distal edge of the film distal to the mesial edge of the first molar to ensure imaging
the entire tooth.
Tip to Image the Mandibular Canines and Incisors

You should be able to image all 8 mandibular incisors and canines on one view.
Place the patient in dorsal or lateral recumbancy, with the head fully extended. It will help to place a roll
under the neck to keep the mandible parallel to the table. The sensor is placed squarely in line with the canine so
the film sticks out just in front of the incisors. The tube head is placed straight on with the head, perpendicular to the
Advanced
film. Rotate the tube head down to an angle that is approximately 75 to 80 degrees to the film.
Maxillary Incisors
Radiographs of all maxillary teeth are taken utilizing the bisecting angle technique. The patient is placed in
sternal or lateral recumbancy with the head slightly elevated to keep it level with the table. The film is placed in the
mouth so that the maxillary canines are resting on it and a small amount of the film is in front of the incisors. The
tube head is positioned parallel to the long axis of the head in the horizontal plane and angled approximately 80
degrees to the film in the vertical plane, which is the approximate bisecting angle for the distally curved roots.
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Maxillary Canines
The maxillary canines of the feline are much easier to obtain than in the canine due to the relatively short
roots. Each maxillary canine needs to be imaged separately. This is due to the fact that their roots lie over the
maxillary second and possibly third premolars depending on the angle. The patient is positioned in sternal or lateral
recumbancy with head propped up and extended. The film is placed in the mouth between the maxillary canines with
Generalist
the front of the film at approximately the level of the incisors, making sure to have the distal edge of the film at least
to the level of P3. Start with the tube head positioned straight on with the nose angled at about 80 degrees to the
film due to the backward sweep of the canines. Once in position, rotate the tube head around the cat’s head
approximately 70 degrees. This positioning allows for the root of the maxillary canine to be projected towards the
palate where no tooth obstructions are found, giving a clear radiograph of the tooth. Note that in bracheocephalic
breeds, further rotation of the tube-head in the horizontal plane may produce a better image.
Tip for Easily Exposing Canines

Once the film/sensor is in position for the incisors. Leave the sensor in place and just rotate the tubehead 20
degrees laterally.
Maxillary Molars and Premolars

Radiographs of the maxillary cheek teeth are the major difference between canine and feline patients. In the
canine, quality radiographs of these teeth can be exposed with the standard bisecting angle technique. However, the
Para-professional
position of the zygomatic arch in the feline patient does not allow a clear view of the third and fourth premolars using
this technique since it will be superimposed over these roots. To perform this radiograph, the patient is positioned in
sternal or lateral recumbancy with head extended. The cusp tips of the teeth to be imaged should be resting on the
Track A
film, which is relatively flat against the palate. The tube head is centered over the entire arch to be radiographed and
angled at 45 degrees to the film.
Tip to Expose the Distal Root of P4 and M1

Because of the fact that the zygomatic arch curves outward around the distal root of the P4, it is quite
common for practitioners to expose an image shot with the mesial tube shift. The result of this progection is that the
first molar as well as the distal root of the fourth premolar are often off the back of the image. To fix this rotate the
tubehead distally to point towards the nose. This will image the roots correctly.
Tip to Balance the Vertical Angulation

Cats have a slight rotation to the maxilla which results in the distal root of the P4 having a different angle
than the mesial roots and P3. Therefore you will need to balance elongation of the mesial part with foreshortening of
the distal.
The above gives you a representative image of the premolars, but causes superimposition of the zygomatic
arch over the teeth. This will obscure the tooth roots significantly.
Due to this limitation, two additional techniques are now currently utilized to get a clear image of these tooth roots
Tips for Removing Zygomatic Arch

Extra oral Technique: This method is difficult to master, but it allows these teeth to be visualized without
interference of the zygomatic arch or elongation of the roots. Place the film on the table with the embossed dot
facing up and then place the patient in lateral recumbancy with the teeth to be imaged down on the film. The film
should be placed so that the ventral side is just visible below the cusp tips of the teeth to ensure that the majority of
the film is available to image the roots. In addition, make sure that the film covers the teeth from the second
premolar to the first molar in the rostral-caudal direction. For this view, a size 4 film is generally used to reduce
placement errors.
Place a gag (preferably radiolucent) in the mouth between ipsilateral cuspids to open the mouth fairly wide.
The head should be slightly rotated so that the mandible is about 20 degrees above the maxilla and then the tube
head positioned pointing into the oral cavity such that the cusp tips of the opposite arcade will be imaged
approximately 3 mm below the root apices of the arcade to be imaged (approximately 25 degrees from
perpendicular). This gives the approximate 45 degree angle necessary to accurately depict the root length.
Advanced
Variation on the angle depends on the anatomy of the particular patient. Splitting of the tooth roots (SLOB rule) is
very difficult to achieve in this view. If this is critical, use the acute angle technique below.
One important point to remember when utilizing the extra oral technique is that the film needs to be marked
in some way to distinguish right vs left. This is due to the fact that the embossed dot is now facing into the mouth as
opposed to out of the mouth in the intra-oral techniques. Therefore, when the films are viewed they will be
interpreted as the contralateral arcade. In our practice the embossed dots on dried films are filled in with a red
permanent marker to denote the extra-oral technique was utilized. Other practices will mark an L or R on the film
with a permanent marker or use small paper clip markers prior to exposure.
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Acute angle technique: This technique is similar to the standard bisecting angle; however the teeth are
purposefully elongated to remove the zygomatic arch interference. There are two options to perform this technique.
The first is to perform a standard bisecting angle technique but angling the beam at 30 degrees as opposed to 45.
This will move the zygomatic arch and elongate the film.
This author prefers to change the angle of the film and the beam to decrease the elongation distortion. This
Generalist
generally results in a thin line over the root, but significantly less elongation. The patient is placed in sternal or lateral
(with the teeth to be imaged up) recumbancy depending on personal preference (this author finds that lateral
recumbancy is easier for patient positioning). A gag is placed between the contralateral ipsilateral cuspids to hold
the mouth open. The film is placed in the mouth touching the palatal surface of the opposite arcade and angled
towards the mandible to create an approximate 30 degree angle (often a positioning aid such as gauze is necessary
to hold the film in place). Finally, the tube head is placed so that there is an approximate 60 degree angle between
the film and the tube head.
This technique lends itself to splitting the mesial roots of the upper fourth premolar better than the extra-oral
technique. This author finds that the mesial tube shift works best in feline patients due to the close proximity of the
third premolar mesially and the smaller first molar distally.
References
1. Niemiec BA: Dental, Oral, and Maxillofacial Disease--A Color Handbook, Manson Publishing Ltd, London
2010
Para-professional
2. Dental radiology simplified educational poster and DVD, vetdentalrad.com
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Feline Bones: Musculoskeletal Review

Zoe Lenard, BVSc (Hons), FANZCVS (Radiology)
Generalist
Introduction
Cats are not small dogs! Diseases affecting the feline musculoskeletal system have elements that are
species specific but get less space allocated in radiographic textbooks. This lecture will review diseases of feline
bones using case-based examples, including neoplastic disease, degenerative disease, metabolic disease, and
juvenile disease.
Technical Issues
Careful attention to radiographic technique is required for feline extremities, because they are small
structures without much surrounding soft tissue. For computed radiography (CR) systems, a table-top technique
should be used and image quality tends to be best with very low kVP (in the range of 48-50) and slightly higher mAs
(~8-10), although this will vary according to anode output. CR tends to respond more like old fashioned film, and
works well with a low kVp technique to maximize the crispness of trabecular bone detail. For direct digital (DR)
Para-professional
systems, there tends to be less sensitivity to low kVP and bone detail may be excellent with low mAs (2.5) and higher
kVp techniques. Refer to the specifications provided by your vendor for more detail.
Avoid over-collimation with digital systems: it is generally better to have 30-50% of the image receptor
exposed in each projection. So if this means one small cat paw in the middle of a large amount of “black”, so be it.
Track A
Over-collimation may confuse the computer processing algorithms. Keeping radiation safety in mind at all times, all 4
edges of the beam should be visible on the image, but scatter is not a significant issue in radiography of small
structures. Avoid taking multiple images on the one plate (e.g. a lateral projection on one half of the plate, followed by
a DP projection on the other half). Not only is this difficult to display and store digitally, it can also confuse the
processing algorithms resulting in reduced image quality.
Sedation
The author prefers to sedate patients routinely for radiography (thorax, abdomen, MSK) as it minimizes
patient stress, allows appropriate radiographic positioning, and avoids staff being in the room during exposure. Low-
doses of opioid sedatives, with the addition of acepromazine or benzodiazepines, are safe for most conditions and
well tolerated. For fractures of any bones or spinal/head radiography, general anesthesia may be preferable to
sedation for adequate position and better pain management.
Tumors
1
Unlike canine patients, primary bone tumors in cats are rare. Appendicular OSA has prevalence for the
pelvic limbs, and has been reported to arise at the site of previous fracture repair. Axial OSA is also common with a
1
predilection for the skull. Interestingly extra-skeletal osteosarcoma was common in a large retrospective study, with
55 of 145 cases occurring in this category, predominantly arising from subcutaneous tissues in areas associated with
1
vaccination. Generally appendicular osteosarcoma had a low metastatic rate with long survival times after
amputation; survival times tend to be shorter with axial osteosarcoma.
Other aggressive soft tissue sarcomas that locally invade bone (squamous cell carcinoma) appear to be
more common than osteosarcoma in cats, particularly in the maxilla or mandibles with the gum being the likely site of
2
origin of the tumor. These lesions may be highly locally invasive, extending into the deeper tissues of the face
(including the orbit and may be a source of dental discomfort or tooth loss. Whilst distant metastatic disease is
reported to be rare with SCC, metastases can occur. One report of a pulmonary SCC illustrated widespread
metastatic disease with clinical lesions detected in pelvic and scapular bones, suggesting that SCC arising from
3
tissue s other than the face may have greater metastatic potential.
Other aggressive bone tumors (including fibrosarcoma, chondrosarcoma) are reported sporadically in the
2,4
literature and atypical bone lesions (lymphoma, hemangiosarcoma, plasma cell tumor) have also been reported.
The so-called “lung-digit” syndrome describes an unusual syndrome seen in cats where bronchogenic carcinoma
Advanced
5
metastasizes to the digit, with patients presenting primarily for lameness, not respiratory signs like coughing.
Radiographically the lesion shows lysis of the distal phalanx (P3) and occasional lysis of the middle phalanx (P2).
Multiple digits can be affected in the same foot, or in different feet. Nodules or masses are visible radiographically in
the lungs. Primary digital squamous cell carcinoma is also reported in the cat though it may be less aggressive than
6
the lung-digit syndrome. Any cat presenting with lameness or paronychia should prompt radiographic assessment
of multiple digits and thorax.
Cats presenting with lameness and swelling of a limb require two orthogonal projections of the limb centered
on the swelling, including the joint proximal and distal to the swelling. Radiography of the contralateral limb at the
same time may be useful to help compare anatomy. Radiography of the head, particularly the face, is challenging
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due to the small size and complex contours creating superimposition of structures. Intraoral projections may not be
possible. For examination of lesions arising in the head, consider CT as a superior test. Radiography of the axial
skeleton may show lytic or productive lesions, but CT (especially with IV contrast) does tend to better define the
extent of the lesion. Despite the lower metastatic potential of feline bone tumors, thoracic staging at the time of the
initial radiographic examination is recommended (obtain a three-view thoracic study consisting of both left and right
Generalist
lateral projections and a VD projection). If CT of the head or axial skeleton has been performed, it is easy to obtain
thoracic CT at the same time, with better sensitivity for the detection of small pulmonary nodules.
Radiographing the digits is straightforward, with a dorsopalmar (dorsoplantar) projection being easily
obtained. There is limited use for a straight lateral projection due to digital superimposition; a splayed-lateral is
preferable and achieved by using a small amount of tape to separate digits 1 and 4 in opposite directions thereby
improving visibility of all digits.
Radiography or CT will not provide definitive diagnosis in any case of suspected neoplasia: biopsy with
histopathology will be required. Pathological fracture may be a common sequelae in tumors affecting the limbs.
Aggressive-appearing Lesions that are not Tumors

Osteomyelitis may be a differential for an aggressive appearing bone lesion (i.e. one with lysis and/or a
7
palisading or interrupted periosteal reaction). Signalment and history may help with narrowing the differential list,
especially is there is a wound, history of a wound, or discharging sinus (e.g. a cat bite lesion). A mid diaphyseal
location of the lesion in a long bone may be more common with hematogenous osteomyelitis, especially if fungal in
Para-professional
8
etiology, although fungal osteomyelitis can occur in metaphyseal locations, particularly in young animals. Chronic,
bacterial osteomyelitis can have a less-aggressive appearance with smooth-solid periosteal reaction and marked
sclerosis of the bones. Biopsy with histopathological assessment and culture may be required. In the skull, chronic
Track A
periodontal disease and tooth root abscessation can lead to osteomyelitis of the mandibles, which again may mimic
neoplastic disease.
The detection of extensive, organized, extra-skeletal mineralization in soft tissues (heterotopic bone) in the
fascia between muscles is suggestive of fibrodysplasia ossificans progressiva (previously described as ossifying
9
myositis). This disease is rare, affecting young or middle aged cats; it is poorly understood, perhaps with a genetic
component. Generalized movement is restricted and cats lose weight with marked clinical deterioration. This
condition should be differentiated from mineralization of tissues at just one site occurring subsequently to trauma and
inflammation (localized myositis) with clinical signs caused only by encroachment of the mineralized tissue on the
7
nearby joint.
Genetic Bone Diseases

Scottish Fold osteochondrodysplasia is a progressive disease affecting the Scottish Fold breed, a
brachycephalic cat breed with forward-folding ears. Malik and coworkers published an excellent review on the
10
condition with observations on the radiographic lesions in 6 cats. It is thought inheritance is a single autosomal
dominant trait, meaning all homozygotes for the gene will be affected, but so will heterozygotes, although with milder
or subclinical disease. Cats can present with clinical signs of lameness at very young ages (3 months) but lameness
is also reported in older cats (e.g. 6 years old).
The folded ear in this breed is indicative of a widespread defective cartilage gene which manifests as skeletal
deformities occurring during bone growth, including short metacarpal and metatarsal bones, splayed phalanges and
10-11
shortened caudal vertebrae creating a short and thick tail. As cats age there is a progressive ankylosing
polyarthropthy affecting distal limb joints, with the pelvic limbs affected earlier. Large, smooth, periosteal reaction
forms around the tarsal and carpal joints mineralization can occur in the tendons and joint capsule reflecting
abnormal stresses on the joint as the defective structure collapses under the weight of the cat. Radiographs have a
10
characteristic appearance in the breed. Treatment can be challenging as the disease is relentlessly progressive.
Mucopolysaccharidosis refers to a group of lysosomal storage diseases caused by accumulation of
11
glycosaminoglycans in tissues, some of which result in arthropathies in cats. Affected cats present with dwarfism,
7,11
facial dysmorphia and lameness reflecting radiographic malformations in the skull, spine and limbs.
Radiographically cats have a normal sized cranial vault with short maxilla and facial bones, short square vertebral
bodies that are prone to fusing, coxofemoral subluxation and flaring of the distal aspects of the ribs. An increased
incidence of degenerative joint disease in the shoulder and stifle joints has been noted in a breeding colony of MPS
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12
cats.
Although rare, these diseases may appear from time to time in practices that see a high number of cats and
may present in middle-aged to older cats. Clinicians need to have a general awareness of the presence of genetic
disease and the breeds affected; if suspicious that one of these diseases is present consider obtaining survey
skeletal radiographs, including lateral projections of the spine, a VD projection of the pelvis, lateral and
dorsopalmar/plantar projections of the carpi and tarsi.
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Nutritional Diseases
The widespread availability of balanced diets has resulted in a decrease in the incidence of nutritional
diseases in feline populations, but a general awareness of the manifestations of these diseases should be
maintained.
Nutritional secondary hyperparathyroidism may manifest in kittens fed an inappropriate diet, resulting in
Generalist
7
generalized osteopenia and propensity to develop cortical folding fractures particularly in the pelvis and spine.
Cats are unable to synthesize vitamin D from sunlight and are completely dependent on dietary sources.
Rickets caused by dietary vitamin D deficiency is rare, but may be caused by an inborn error in vitamin D
13
metabolism. Characteristic diffuse osteopenia with flared and mushroom-shaped metaphyses in the long bones are
typical. Correction of the nutrition deficiency should lead to resolution of these diseases.
Hypervitaminosis A is a toxicity created by a diet rich in vitamin A resulting in an ankylosing spondylopathy,
11
and proliferative bone formation around the shoulder and elbow joints. If caught early, dietary correction may
resolve the condition; unfortunately once the lesion is clinically detectable the bony changes are not reversible.
14
Osteochondrosis is rare in cats but is reported in captive wild cats with very few reports in domestic cats in
the literature. The author has seen a number of cats present with stifle osteochondrosis appearing similarly to the
condition described commonly in dogs (subchondral bone defects in the distal femur associated with mild sclerosis
and marked associated joint effusion, causing lameness). Etiology is unknown but presumed to be nutritional, or
perhaps, in the case of the cheetahs, both nutritional and genetic.
Para-professional
Femoral Head and Neck Disease
Young cats (less than 2-3 years of age) may present with acute onset pelvic limb lameness which is not
related to obvious trauma due to pathology in the femoral head or neck. Diagnoses may include capital physeal
Track A
fractures (unilateral or bilateral) or metaphyseal osteopathy. Both conditions tend to affect young, male neutered,
obese cats; the late closure of the femoral capital physes at up to 40 weeks of age may play a role in the a etiology of
disease. In the case of physeal fracture, open growth plates are more susceptible to slipping. In metaphyseal
15
osteopathy, the condition may be analogous to avascular necrosis of the femoral head in dogs although the
condition is poorly understood. In either case, the lesion may be missed on frog-legged VD projections due to poor
ability to see the physis clearly, and VD-extended projections are warranted. This may be more painful and typically
requires heavy sedation or anesthesia.
Arthritis: Degenerative vs. Inflammatory

Degenerative joint disease certainly occurs in cats and shares many radiographic features with the disease
in dogs. Key differences between cats and dogs in the manifestation of osteoarthritis of the hip joint are cats are
more tolerant of hip laxity than dogs (thus not being as clinically affected by HD than dogs) and cats have a different
radiographic phenotype compared to dogs (cats lay down osteophytes on the cranial acetabular margin rather than
the femoral neck). As discussed earlier, osteoarthritis will be more severe in cats with genetic conditions including
Scottish Fold osteochondrodyplasia, mucopolysacchariosis and nutritional diseases including hypervitaminosis A.
The shoulder, elbow and stifle joints are common sites of advanced primary degenerative joint disease; a
review of lateral radiographic projections of the thorax and abdomen in older cats will likely show proliferative bony
change affecting these joints on the edge of the study. Mineralized periarticular masses are common and likely
11 16
represent synovial osteochondromatosis, nodules of cartilage undergoing synovial metaplasia. A recent review
suggests that synovial osteochondromatosis is a common manifestation of degenerative joint disease, i.e. a benign
lesion, rather than a specific separate condition, reminding practitioners not to confuse it with an aggressive
neoplastic condition like chondrosarcoma.
Immune-mediated polyarthropathies (rheumatoid arthritis, progressive proliferative polyarthropathy, systemic
lupus erythematosus and idiopathic polyarthritides) are a differential for arthritis. Clinical suspicion should be raised
in young cats with shifting lameness affecting multiple joints. Joint effusion is a feature, although it may not be
radiographically evident in every joint. The non-erosive arthropathies may not have radiographic features apart from
effusion in the early phases; chronically they may mimic other degenerative arthroses. Erosive polyarthropathies are
rare, but show destruction of subchondral bone and collapse of joint spaces in addition to marked increase in joint
11
swelling. High-quality radiographs of multiple joints should be obtained, particularly the carpus (DP projections), the
tarsus (DP and lateral projections). Finally, infective arthropathies (including Mycoplasma sp., Pasteurella, calcivirus)
Advanced
are non-erosive, causing radiographically non-specific signs (joint effusion). Radiographs are indicated in all cases of
lameness associated with joint effusion but are poorly specific and further testing (like arthrocentesis) will be
necessary.
References
1. Heldmann EH, Anderson MA, Wagner-Mann, C. Feline Osteosarcoma: 145 cases (1990-1995). J Am Anim
Hosp Associ 36:518, 2000.
2. Quigley PJ, Leedale AH. Tumors involving bone in the domestic cat: a review of 58 cases. Vet Path. 20:670,
1983.
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3. Dhaliwal RS, Kufuor-Mensah E. Metastatic squamous cell carcinoma in a cat. J F Med Surg 9, 61, 2007.
4. Mellor PJ, Haugland S, Murphy S et al. Myeloma –related disorders in cats commonly present as
extramedullary neoplasms in contrast to myeloma in human patients: 24 cases with clinical follow up. J Vet
Intern Med 20, 1376, 2006.
5. Gottfried SD, Popovitch CA, Goldschmidt MH et al. Metastatic Digital Carcinoma in the Cat: A retrospective
Generalist
study of 36 cats (1992-1998). J Am Anim Hosp Assoc 36, 501, 2000.

6. Lui S, Dorfman JD, Patnaik AK. Primary and secondary bone tumors in the cat. J Sm Anim Pract 15. 141,
1974.
7. Schrader SC, Sherding RG: Disorders of the Skeletal System. In Sherding RG, editor: The Cat: Diseases
nd
and Clinical Management. 2 Edn, Churchill Livingstone, 1994, p1640.
8. Hess MO. Phaeohypomycotic osteomyelitis in the femur of a cat. J Feline Med Surg 11: 878, 2009.
9. Bb
10. Malik R, Allan GS, Howlett CR et al. Osteochondrodysplasia in Scottish Fold cats. Aust Vet J 77:85, 1999.
11. Allan GS. Radiographic features of feline joint diseases. Vet Clinics of Nth America 30, 281, 2000.
12. Crawley AC, Neidzielski KH, Isaac EL et al. Two mutations within a feline mucopolysaccharidosis type VI
colon cause three different clinical phenotypes. J Clin Invest 101:109, 1998.
13. Philliips AM, Fawcett AC, Allan GS et al. Vitamin D-dependant non-type 1, non-type 2 rickets in a 3 month
old Cornish Rex Kitten. J Feline Med Surg 13;526, 2011.
14. Allan G, Portas T, Bryant B et al. Ulan Metaphyseal osteochondrosis in seven captive bred cheetahs. Vet
Para-professional
Radiol Ultrasound 49;551, 2008.

15. Lafuente P. Young, male neutered, obese, lame? Non traumatic fractures of the femoral head and neck. J
Feline Med Surg 13:498, 2011.
Track A
16. Tan C, Allan GA, Barfield D et al. Synovial osteochondroma involving the elbow of a cat. J Feline Med Surg
12:412, 2010.
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Do Cats Have 9 Lives? Imaging in Cases of Feline Trauma

Generalist
Introduction
Cats have a remarkable ability to survive and bounce-back from serious trauma but understanding
accurately the extent of problem early in the work-up is vital. This lecture will review the imaging approach to trauma,
from selecting the best initial test (radiography, ultrasound, CT) to monitoring treatment. Examples covered include
spinal trauma, urinary tract trauma, subtle fracture disease and managing imaging in the dyspneic feline.
First Things First: Getting the History and the Careful Clinical Examination
Traumatic injuries affect cats from any age, and from any background (i.e. in-door and outdoor cats). In a
1
recent study of English cats trauma was the leading cause of death in young cats resulting in nearly 50% of
mortality; it remained a significant cause of death in middle age and older cats causing ~ 6% of mortality. In both
categories, the most common cause of trauma was road traffic accidents. Road trauma tends to be high-impact, and
may result in significant musculoskeletal and neurological damage, as well as blunt trauma to the abdomen. Other
2
Para-professional
common causes of trauma include falls (incorporating high-rise syndrome ) and animal attacks (incorporating cat or
dog bites).
When approaching imaging of feline trauma, it helps to consider into three categories according to the body
region affected
Track A
1. The respiratory system
2. The neurological and musculoskeletal system
3. The abdomen affected by blunt trauma.
Severe trauma in all categories may result in cats presenting in various forms of shock and close to death,
but it is trauma affecting the respiratory system which often causes the most delicate situation. Careful assessment
of respiratory rate prior to removing the cat from the carrier/cage is warranted. In any case of respiratory trauma,
minimizing stress is paramount. Emergency first principles (providing an oxygen-rich and quiet environment, getting
venous access and stabilizing shock apply to all cases of trauma) before imaging should be performed.
Respiratory Trauma
In cat presenting with dyspnea and/or tachypnea, thoracic radiography is essential. If the traumatic event has
been witnessed, the differential list will narrow markedly (pneumothorax, hemothorax, pulmonary contusions,
diaphragmatic hernia and pain caused by fracture of the thoracic skeleton). If no trauma has been visualized
common non-traumatic differentials, including feline bronchial disease or congestive heart failure, need to be
excluded regardless of patient age.
Submitting a cat with respiratory distress to radiographs may be high-risk, and every attempt to stabilize the
patient first should be made. A single dorsoventral projection of the thorax is the safest option initially with
supplementary oxygen provided. Placing a radiolucent (foam) pad between the table and the cat may help to keep
the cat comfortable, and limit pressure on elbows and tarsal joints. Allowing the cat to keep their head elevated will
also help most dyspneic animals. The author prefers to use a small foam pad/wedge placed under the cat’s chin to
achieve this, ensuring that the face is free without anything touching the whiskers. Flow-by oxygen or a face mask (if
tolerated) may provide additional support.
The dorsoventral thoracic projection will allow evaluation of whether significant pneumothorax or pleural
effusion is present, and whether the disease is symmetrical or affects one pleural cavity more severely. It may be
possible to assess cardiac silhouette size, although a pleural effusion may mask the cardiac silhouette. Evaluation of
the ribs for symmetry and position may allow identification of rib fractures or body wall trauma. Following this
radiograph, further appropriate treatment can be instituted (e.g. thoracocentesis).
Avoid lateral radiographs in the most unstable patients: the stress of the examination and restraint may
induce cardiorespiratory arrest. A DV projection may result in less than ideal positioning, with curvature of the spine
(a “banana-shaped” spine); this is usually remedied with a VD projection; however in respiratory compromise placing
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an animal in ventral recumbency is likely to further reduce any respiratory reserve.

Following the DV projection, consider thoracic wall ultrasound examination. It is beneficial to avoid moving
the patient too much in stage, so if you can set up an ultrasound examination in radiology, additional stress may be
avoided. Techniques for the evaluation of the thorax in an emergency situation with ultrasound have been recently
3
established, so-called Focussed Assessment with Sonography for Trauma (FAST). Scanning the lower third of the
thorax with the patient in sternal recumbency will allow for identification of pleural fluid; scanning over the dorsal and
mid thirds of the thorax may allow for identification of pleural air. These techniques describe an approach in detail
suggesting that radiography might be replaced. It is the opinion of the author that these tests should be used in
combination with high-quality radiographs for a more global assessment of disease. Further, obtaining a second
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opinion from a reliable teleradiology service is possible with radiographs, but may not be possible with the Thoracic-
FAST exam. The use of FAST tests remains an excellent option for ongoing monitoring of the patient in hospital (i.e.
looking for hemorrhage in the abdomen/thorax, or the development of pneumothorax).
Once the patient is stable, obtaining lateral projections (ideally both right and left recumbent views) is
recommended to confirm the diagnosis. Traumatic conditions like pneumothorax and pulmonary contusions may
Generalist
require repeated assessments after treatment (especially in thoracic drains are attached). Additional radiographic
views (e.g. the abdomen, the neck) may be indicated. Including the abdomen in the thoracic study may aid diagnosis
4
of diaphragmatic hernia. Unusual causes of tachypnea and dyspnoea can include pneumomediastinum even when
concurrent pneumothorax is not present.
Neurological and Musculoskeletal Trauma

Inability to walk is a common feature of cats who have suffered trauma. In a study of 119 cats with high-rise
2
syndrome 55% had fractures of the limbs or pelvis. Whilst fractures of the limbs tend to be easy to recognize in the
clinical exam, fractures of the pelvis and spine can be challenging to palpate and may present with concurrent
neurological deficits.
For any cat suffering a traumatic episode, whether they present with respiratory signs or not, thoracic
radiography is recommended. The author recommends that radiographs are obtained in a conscious or lightly
sedated patient, prior to anesthesia (e.g. to rule out pneumothorax, diaphragmatic hernia or other conditions that may
result in decompensation once anesthesia is induced). Radiography of any suspected fracture requires anesthesia,
Para-professional
however, as pain may prohibit positioning for diagnostic views. Two orthogonal views are required in all cases! For
complex regions like carpal and tarsal joints, or in juveniles with open physes, consider obtaining the contralateral
limb at the same time for comparison.
Track A
For pelvic radiographs, obtain a lateral projection to help with assessment of the lumbosacral junction, and
two VD projections. A neutral “frog-legged” projection of the pelvis allows assessment of the coxofemoral joints but is
poor for assessing the femoral head and neck. Subtle fractures in these regions may be missed without the VD-
extended projection (a projection which tends to be more painful when any pelvic or pelvic limb fracture is present).
5
Radiography has a much lower yield that advanced imaging (CT/MRI) for the assessment of spinal fractures
particularly as plain radiography is poorly sensitive for fractures of the vertebral canal resulting in spinal cord
compression and spinal subluxations. In pelvic fractures, CT allows for more accurate assessment of the sacroiliac
6
joints, the acetabulum and soft tissue trauma. The ability to create mutliplanar reformats and 3D volume rendered
images helps with surgical planning, as well as accurately conveying the extent of the trauma to owners. Further,
evaluation of the soft tissues (particularly in the abdomen, including the body wall and urinary tract) is easily
performed with CT, including ruling out urinary tract rupture.
For spinal radiographs, start with a well-positioned lateral radiograph. Given cats are small, at least two
radiographs are ideal for assessing the spine; fitting the whole length of the spine into one image may result in
interpretative error with the parallax effect. Aim for the cervical and thoracic spine (lateral when the costochondral
junctions are superimposed), and the thoracolumbar to pelvic spine (lateral when the transverse processes of the
lumbar spine are superimposed). VD projections are recommended particularly if pelvic or lumbosacral disease is
suspected; however if you suspect spinal fracture or luxation, obtaining CT of the spine in the first instance is
superior. For both CT and radiography, position the cat in dorsal recumbency (perhaps in a foam V-trough) to align
up the spine in the sagittal plane and optimize the visualization of fractures.
Head trauma is accurately assessed with CT (see more on this in the lecture CT of the Feline Head). MRI of
the head can be great for assessing both bony and soft tissue disease, particularly intracranial disease (oedema,
7,8
hemorrhage). Traumatic intervertebral disc prolapse does occur in cats and may be detected with both CT and
MRI.
Blunt Abdominal Trauma

This type of trauma may not cause obvious or immediate signs, but can also have severe consequences
resulting in death. Injuries occur with motor vehicle accidents, falls and crushing injuries that may occur particularly
with dog-attacks. The choice (and order) of which imaging modality to perform will depend on what is available to the
practitioner and the degree of cardiovascular shock present (i.e. simple tests like radiography can be performed very
rapidly, whereas ultrasound and CT may not be available in the first instance); ultimately there is ideal no “recipe” to
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be followed and each case should be assessed individually.

Abdominal radiographs (VD and a lateral projection) are always useful as a first-line test in the opinion of the
author, as they provide a global assessment of the peritoneal cavity, lumbar spine and pelvis as well as the edge of
the thorax and can be obtained rapidly (unlike ultrasound, which is operator dependent). Subtle changes like loss of
serosal or retroperitoneal detail may imply hemorrhage or urinary tract rupture. In the case of urinary tract rupture,
contrast radiography remains superior to ultrasound for the detection of the location of rupture (see the notes below
about CT). Pneumoperitoneum suggests intestinal or body wall perforation and the integrity of the body wall can be
assessed. Radiographs can be performed safely in the emergency setting (i.e. after hours) and serial radiographs
may allow for detection of deterioration.
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Sonography is excellent for assessment of the visceral organs, but is highly operator dependent. The use of
3
recently developed FAST abdominal ultrasound protocols for the assessment of peritoneal fluid (hemorrhage) is
helpful for practitioners, but determining the source of hemorrhage with ultrasound may be difficult. Exploratory
laparotomy will not replace ultrasound in many cases.
Generalist
The use of CT for assessment of blunt abdominal trauma in the human setting is controversial, with a
number of recent publications suggesting that if children are hemodynamically stable after blunt abdominal trauma,
9-10
the information obtained by CT may not add to existing diagnostics. This controversy centers on the risks of
increased radiation dose from CT in a pediatric population, concerns that we tend not to face with our veterinary
patients. Further, children in hospital may have had a raft of additional tests and monitoring those veterinary patients
may not be exposed to.
CT of the abdomen in trauma cases is an excellent option if the patient is stable enough for anesthesia or
sedation, and could replace radiography and ultrasound as a diagnostic test. Ensure any circulatory shock has been
11
corrected; admiration of IV contrast is essential for this examination but can be renotoxic in dehydrated patients. CT
will accurately assess body wall trauma, detect small volumes of pneumoperitoneum, allow for ruling out spinal and
pelvic fractures, allow assessment of the urinary tract and exclusion of rupture, and may allow the detection of a
source of parenchymal hemorrhage. Interpretation of the abdomen can be complex and consultation with a
veterinary radiologist is strongly recommended.
Para-professional
References
1. O’Neill DG, Church DB, McGreevy PD, Thomson PC, Brodbelt DC. Longevity and mortality of cats attending
primary health care veterinary practise in England. J Feline Med Surg 2:125, 2015.
Track A
2. Vnuk D, Pirkic B, Maticic D, Radisic B, Stejskal M, Babic T, Kreszinger M, Lemo N. Feline high rise
syndrome. J Feline Med Surg 6:305, 2004.
3. Boysen SR, Lisciandro GR. The use of ultrasound for dogs and cats in the emergency room AFAST and
TFAST. Vet Clin Small Anim 43:773, 2013.
4. Thomas EK, Syring RS. Pneumomediastinum in cats: 45 cases. J Vet Em Crit Care 23, 429. 2013.
5. Kinns J, Mai W, Seiler G, Zwingenberger A, Johnson V, Caceres A, Valdes-Martinez A, Schwarz T.
Radiographic sensitivity and negative predictive value for acute canine spinal trauma. Vet Radiol Ultrasound
47: 563, 2006.
6. Crawford JT, Manley PA, Adams WM. Comparison of computed tomography, tangential radiography and
conventional radiography in evaluation of canine pelvic trauma. Vet Rad Ultrasound. 44, 619, 2003.
7. Maritato KC, Colon JA, Mauterer JV. Acute non-ambulatory tetraparesis attributable to cranial cervical
intervertebral disc disease in a cat. J Feline Med Surg 9:494, 2007.
8. Harris JE, Dhupa S. Lumbosacral intervertebral disc disease in six cats. J Am Anim Hosp Assoc 44, 109,
2008.
9. Nellensteijn DR, Greuter MJ, El Moumni M, Hulscher JB. The use of CT in hemodynamically stable children
with blunt abdominal trauma: Look before you leap. Eur J Pediatr Surg E Pub May 27 2015.
10. Acker SN, Stewart CL, Roosevelt GE, Patrict DA, Moore EE, Bensard DD. When is it safe to forgo abomdial
CT in blunt-injured children? Surgery E Pub May 18 2015.
11. Bettmann MA. Frequently asked questions: Iodinated Contrast Agents. Radiographics 24:S3, 2004.
NOTES:
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Feline Thoracic Radiographs: Interpretive Principles & Normal Variations

Lorrie Gaschen, PhD, DVM, Dr.med.vet, DECVDI
Generalist
Standard Projections
Right and left lateral recumbent and ventrodorsal radiographs are adequate for most examinations of the
thorax. Dorsoventral views can additionally be performed. Performing a 4-view examination would include both the
ventrodorsal and dorsoventral views and this is referred to as “positional radiography”. The reviewer should keep in
their mind that they may need another view. Additional projections include a “humanoid” view, oblique views and
horizontal beam projection, which will be discussed later. Regardless of the projection, the systematic analysis is
important.
Systematic Review
Firstly, the quality of the images is of paramount importance for lesion detection. The image should be
centered at the heart, basically at the edge of the caudal border of the scapula with the forelimbs extended,
regardless of the projection. In the VD or DV image, the sternum needs to be superimposed with the vertebral
Para-professional
column in order to best examine the lungs and shape of the heart. Next, don't look at the heart first. This is a
common tendency and often leads to missing lesions in other regions of the anatomy, like the cranial abdomen.
Trace the outer margins of the radiograph with your eyes. Then, assess body condition, cranial abdomen for serosal
detail, skeletal structures and caudal cervical region. Once structures external to the thoracic borders are assessed,
analyze the overall opacity of the thorax. Determine if the opacity is due to thin (hyperlucent) or obese (increased
opacity) body condition. This assessment sets the limitations on the ability to diagnose lung disease as well as
reminds the reviewer to be careful about over interpretation and reader bias when under pressure to find an
abnormality. Begin examination of the mediastinum next: trace the trachea to the carina, assess the soft tissue of the
cranial mediastinum ventral to it and move to the pericardial region, then further to the space between the heart and
diaphragm. Dorsally, trace the aorta to the diaphragm. In the VD or DV image, assess the width of the mediastinal
soft tissue, which should not be greater than the width of the vertebral body, but depends on body condition. The
lungs should each be traced out from the carina. I like to trace the trachea to the carina and assess each lung lobe
individually. Assessment of the lung includes the bronchi and vasculature for size and prominence, especially in the
periphery. Lastly the heart and great vessels are reviewed for size and shape as well as margination.
Positional Radiographs
Although there are only subtle differences between the right and left lateral views, this greater variation in the
VD and DV. Most importantly, performing the VD and DV together will aid in the interpretation in obese cats.
Intrathoracic, pericardial and mediastinal fat can be very difficult to distinguish from fluid. Placing the animal in
Track B
different positions and repeating the radiograph will allow fluid to move with gravity while fat will not. Increased
conspicuity of margins of the heart in the VD projection compared to the DV, for example, is one of the best ways to
confirm the presence of pleural fluid. If you are considering mild pleural fluid in the obese animal and do not see
pleural fissures, compare the VD and DV for changes in margination of the heart contour.
Normal Variations
Body Condition
Geriatric, emaciated cats have a hyperlucent thorax, often have sternal malformations, a large lung size and
hyperlucent lungs. This situation will mimic that of asthma, or hypovolemia due to the large lung size and
hyperluceny. Obese cats have an increased opacity of the thorax, large deposits of fat around the heart.
Subsequently, the cardiac silhouette has an unsharp border and the retraction of the lung lobes can be confused with
pleural effusion. DV and VD radiographs are very helpful for differentiating pleural effusion from pericardial fat in
obese cats. The lungs of obese cats will lead to an indistinct appearance of the air-filled lung and vasculature,
making interpretation difficult. Fat can also appear as a mediastinal mass or pleural fluid. In these instances it is
important to perform positional radiography to displace what may be fluid or to use ultrasonography to identify fat and
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differentiate it from fluid and masses.
Skeletal Structures, Shape of Thorax, Ribs, Spine

Congenital defects such as pectus excavatum and carinatum create a compressed appearance of the thorax
in the dorsoventral dimension as the sternum is generally dorsally displaced. This can affect the position of the heart
which may be dorsally or laterally displaced. Geriatric cats may have mild to severe malformation of the vertebrae,
ribs and sternum. Pathologic fractures of the ribs are not uncommon in cats with chronic lower airway disease and
both acute and chronic rib fractures can be discovered incidentally on thoracic radiographs. An undulating shape of
the sternum can also be commonly seen. Due to the flexibility of the cat’s thoracic cage, large variation in inspiratory
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and expiratory radiographs is possible. This can also be used be diagnostically useful. For example, upper airway
obstructions from the nares to the carina can result in dorsal deviation of the sternum and cranial deviation of the
costal arch together with cranial displacement of the diaphragm.
Thoracic wall injury can lead to soft tissue swellings, subcutaneous gas if open wounds are present as well
as pneumomediastinum if the gas dissects along the cervical fascial planes. Cats will react to pain by “collapsing” the
side of the thorax that was injured and that side will appear concave on VD images with decreased intercostal
spacing. The lung volume on the side of trauma may also be reduced, the lungs may be more opaque and the
diaphragm may displace cranially. Pulmonary contusions may also be present and detected due to their severe soft
tissue opacity of the lung. Bite wounds and gun shots to the thoracic wall will often lead to subcutaneous gas
opacities. Flail chest can occur when 2, 3 or more ribs in a row are fractured and thoracic wall function is lost such
that there is paradoxical movement of the chest during breathing.
Mediastinum
The central part of the thorax, the mediastinum divides the right and left halves of the pleural cavity. The
heart occupies the middle part and the cranial and caudal parts are on either side. Normal variants are seen in
kittens as the thymus is large and creates a soft tissue opacity on lateral images in the cranioventral thorax, often in
contact with the cranial border of the heart, sometimes making its border indistinct. This can be mistaken for a
mediastinal mass, sternal mass or pericardial mass. The mediastinum contains most of the intrathoracic vessels and
nerves, the heart, as well as the trachea, lymph nodes and esophagus.
The esophagus is in the mediastinum and is typically not visible unless distended or if pneumomediastinum
is present. Megaesophagus is diagnosed radiographically when it is dilated and either air or fluid-filled. On the VD
image, the esophagus is midline and an increased air or soft tissue opacity may be recognized superimposed with
the spine or adjacent to it. The air filled dilated esophagus has a thin opaque band to the left or both sides of the
vertebral column in the VD image when severely dilated.
Sternal lymph nodes are located at approximately the second or third sternebrae and are generally not
visible when normal in size. This is the same for the tracheobronchial nodes caudodorsal to the main stem bronchi
and the cranial mediastinal nodes ventral to the trachea.
Pneumomediastinum is evident when increased lucency in the thorax outlines the borders of mediastinal
stuctures like the great vessels, tracheal and esophageal walls. It can be progressive and expansile. Common
causes are ruptured bullae or emphysematous lung lesions, chronic bronchitis and rupture due to wheezing and
coughing, tracheal injury (tears and ruptures), and skin wounds.
Mediastinal masses are recognized due to dorsal displacement of the trachea, caudal displacement of the
heart, which can be masked by the presence of pleural effusion. Thymic lymphoma often results in a mass with
effusion and any age cat can be affected. Fluid drainage, positional radiographs and ultimately ultrasonography are
used to detect the masses and perform guided tissue sampling.
Pleura
The pleura is a thin membrane lining the lungs and thoracic cavity and are not radiographically visible.
Track B
Discrete discoid or linear areas of increased soft opacity have been observed within the pulmonary parenchyma in
thoracic radiographs of dogs and cats. Similar radiographic findings have been described in humans and termed
plate-like atelectasis. Plate-like atelectasis was most commonly found in left lateral radiographs. While the etiology
of plate-like atelectasis remains unknown, anatomic variations in sublobar pulmonary anatomy might account for
1
pleural areas of atelectasis. This finding should be considered a normal variant. The pleural structures are must
visible when pleural effusion is present. Mild effusion leads to thin soft tissue bands between the lung lobes and large
volumes lead to retraction of the lung lobes. Other radiographic signs of pleural effusion are rounding of the lung
lobes, loss of distinction of the cardiac silhouette and pulmonary structures due to an increased thoracic opacity,
interstitial appearance of the lung, lack of visualization of the heart due to a superimposed opacity, or a ventral soft
tissue opacity on lateral images. Chronic chylothorax can also lead to fibrous attachments at the lung surface which
become stiffened and retracted, not inflating to their normal shape once the fluid is removed.
Lesions external to the pleural space can cause an “extrapleural sign”. This appears as a broad-based
convex soft tissue opacity against the thoracic wall with its rounded aspect facing the lung. This finding indicates a
lesion in the thoracic wall, intercostal muscle, subcutaneous tissues or ribs. Hematomas, abscesses, cellulitis and
tumors are typical causes.
The cause of pleural effusion cannot be distinguished radiographically, but some features suggest the
etiology. For instance, unilateral effusion walled of to one side of the thorax is typical of pyothorax due to penetrating
foreign body and bite wounds. Transudates and chylous effusions are typically diffusely distributed. Ideally, pleural
effusion should be removed, analyzed and the radiographs should be repeated in the hopes of finding the cause.
Sources of pleural effusion are typical due to disease of the heart, lung, mediastinum, diaphragmatic trauma,
neoplasia and trauma and infection.
84
Pleuritis can be infectious or noninfectious. Chronicity can lead to fibrosis of the pleural linings, visceral and
parietal and these can restrict expansion of the lung. It is often unilateral but can be bilateral. Feline infectious
peritonitis, chronic chylothorax or pyothorax are common causes.
Pneumothorax can be due to closed or open trauma as well as spontaneous secondary to lung disease. The
hallmark of pneumothorax radiographically is retraction of the lungs with a hyperlucent space between them and the
thoracic wall. The pulmonary vessels should be traced to the periphery of the lung and they should travel to approach
the thoracic wall. Vessels cannot be identified in the air-filled pleural space when pneumothorax is present. Tension
pneumothorax is recognized radiographically due to the extreme size of the air filled thorax, severe retraction of the
lung lobes which are atelectic and soft tissue opaque and the caudal position of the diaphragm. Neoplasms and
2
Paragonimus cysts may rupture and lead to pneumothorax.
Lungs
The normal feline lung is very lucent, especially in the periphery and should appear fairly devoid of linear
structures. Most difficulty in examining the feline lung is due to obesity or emaciation. Older emaciated cats tend to
have a hyperlucent, large lung where the bronchial tree if very conspicuous and can be over interpreted as a
bronchial pattern. Hazy interstitial patterns are commonly diagnosed in obese cats with normal lungs. Unfortunately,
short of performing computed tomography, these cats remain difficult to assess. Important is to relate the clinical
signs to the cats radiograph and create an action plan. If the animal has airway signs, then bronchoscopy is the next
logical step. If the cat has no respiratory signs, the lung findings should be interpreted according to the body
condition and other causes such as heart disease should be investigated if an increased respiratory rate or dyspnea
is present.
Heart
The feline heart is perhaps the most variable organ of the entire thorax. The heart position, shape, size and
th th
opacity changes with body condition and age. The heart is located between the 4 -6 rib spaces. Caudal positioning
of the heart can occur with cranial mediastinal masses. When severe pleural effusion is present, the location of the
heart can be estimated by observing the location of the carina. Caudal displacement of the carina can occur with
mediastinal masses and dorsal displacement may be present due to the pleural effusion alone. Heart enlargement is
3
most commonly due to left atrial enlargement secondary to hypertrophic cardiomyopathy. Pericardial disease, such
as effusion and peritoneopericardial diaphragmatic hernia are also fairly common in cats. Pericardial effusion can be
secondary to left sided heart disease, feline infectious peritonitis and lymphoma as a few of the more common
examples. PPDH is often asymptomatic and this finding on thoracic radiographs should be carefully weighed
together with the clinical signs prior to surgical correction so that the actual cause of the presenting disease is not
overlooked due to tunnel vision.
References
1. Giglio RF, Winter MD, Reese DJ, Thrall DE, Abbott JR, Graham JP, Berry CR: Radiographic characterization
of presumed plate-like atelectasis in 75 nonanesthetized dogs and 15 cats. Veterinary radiology & ultrasound
Track B
:the official journal of the American College of Veterinary Radiology and the International Veterinary
Radiology Association 2013, 54:326-31.
2. Greci V, Baio A, Bibbiani L, Caggiano E, Borgonovo S, Olivero D, Rocchi PM, Raiano V:
Pneumopericardium, pneumomediastinum, pneumothorax and pneumoretroperitoneum complicating
pulmonary metastatic carcinoma in a cat. The Journal of small animal practice 2015.
3. Smith S, Dukes-McEwan J: Clinical signs and left atrial size in cats with cardiovascular disease in general
practice. The Journal of small animal practice 2012, 53:27-33.
4. Farrow C. The Thorax. In: Radiology of the Cat. Ed. Farrow C. Mosby, St.Louis, MO. 1994, pp 45-121.
NOTES:
85
NOTES:
Track B
86
Improve Your Interpretation of the Feline Abdomen

Introduction
Systematic review of the abdomen starts with the musculoskeletal system, assessment of the body condition
and shape and size of the abdomen. Next the serosal detail should be assessed and interpreted with respect to the
age of the cat. An organ approach is a good way to work through the abdomen, starting with the liver, spleen,
stomach and small intestines, colon, kidneys and urinary bladder. Every organ should be assessed for its roentgen
sign: size, shape, location, number and margination. Mass effect is a term used to describe displacement of an organ
from its normal location due to a soft tissue opacity.
Peritoneal Cavity
Loss of serosal detail is normal in kittens due to lack of fat in the abdomen. Radiography is still important in
kittens to screen for dilated, gas filled bowel or radiopaque foreign bodies. Ultrasonography is important in young
cats when loss of detail is present or in the presence of peritoneal fluid. Large volumes of fluid will distend the
abdomen. Causes of peritoneal fluid include feline infectious peritonitis, inflammatory peritonitis due to
gastrointestinal perforation or pancreatitis, neoplasia (carcinomatosis), chronic liver disease and right heart failure
(not common).
Pneumoperitoneum can be recognized following abdominal surgery or secondary to gastrointestinal
perforation. The presence of free gas in the peritoneum is a surgical emergency. Penetrating injuries, intestinal
rupture or ruptured uterus. Gastrointestinal rupture in cats is most commonly due to anti-inflammatory therapy and
especially with overdoses. Gas present in the retroperitoneal space has other causes, however.
Pneumoretroperitoneum can be secondary to pneumomediastinum, perianal open wounds (cat bite at tail base),
rectal or genital tract open trauma.
Radiographically, free gas will outline the serosal surfaces of organs, making their borders highly
conspicuous compared to normal. However, small bubbles of gas can be more difficult to assess because they
simulate intraluminal intestinal gas.
When free gas is suspected, it can be confirmed by performing horizontal beam radiography. There are a
number of ways this can be performed. The cat can be placed in dorsal recumbency and left in that position for a few
minutes prior to performing the radiograph, to allow the gas time to collect in the non-dependent portion of the
abdomen. Gas will be visible at the highest point of the body, under the peritoneal surface. A lateral recumbency can
also be used for VD projection of the horizontal beam, and gas will collect under the lateral aspect of the abdominal
wall. Ultrasonographic examination can be subsequently used to identify the source of the free air, but ultimately,
exploratory surgery is indicated.
Track B
Intraabdominal mineralizations may be due to dystrophic or metastatic mineralization, neoplasia and chronic
inflammatory diseases. Specific causes of intraabdominal mineralizations include gastric wall due to uremia,
intestinal foreign bodies or medication, choledocholithiasis, chronic hematomas, abscesses, and cysts, adrenal
glands, urolithiasis (upper and lower tract), pregnancy, and neoplastic masses. Bates bodies are small, rounded
heterogenous mineralizations in the peritoneal space. Focal mineralized circular to oval soft tissue nodule/mass, with
eggshell-like rim, can be found in the abdomen, not associated with any organ. These focal lesions are not common,
however it is more frequently seen in cats than other species. These are usually known as Bates bodies or fat
nodular necrosis. Their etiology is unknown, but it is likely to be related to dystrophic mineralization of necrotic
1
mesenteric fat, secondary to inflammation or ischemia. These are considered incidental findings.
Peritonitis
Peritoneal fluid does not appear homogenous as with diffuse, non-inflammatory or septic causes of free fluid.
The increased soft tissue opacity may have a heterogenous or clumpy appearance. Furthermore, intestinal gas
patterns may appear misshapen. When these features are present, the differential diagnosis is peritonitis or
carcinomatosis.
The dry form of feline infectious peritonitis may also lead to a heterogenous loss of detail as well, even though free
fluid may not be present. This is due to the infiltrative, granulomatous nature of the disease in the mesentery.
Hepatobiliary Disease
An increased size of the liver is the most common abnormality that can be detected radiographically. Any
disease leading to increased fat content (lipidosis), neoplasia, infection and inflammation, and cysts usually lead to
hepatomegaly. The live is enlarged when its size subjectively appears large and supported by caudal displacement
of the stomach. Most important in the cat is that the observer not mistakes the gastric body and antrum for the liver.
The cat’s stomach silhouettes with the liver in the lateral radiography when it is empty or fluid-filled and can appear
87
like an enlarged rounded liver. If unclear, add a small amount of barium or gas to the stomach to identify it as
separated from the liver. A small liver is less common but can be seen due to portosystemic shunt and chronic liver
disease leading to fibrosis. Liver shape changes that can be detected radiographically are usually due to an irregular
border due to cysts or nodules and masses on the liver.
Occasionally, ectopic liver parenchyma can be located at the thoracic side of the diaphragm and it appears
as a thoracic soft tissue mass silhouetting with the diaphragm. They are often mistaken for lung masses.
The liver lobes can also be herniated due to traumatic diaphragmatic rupture or, into the pericardial sack due to
peritoneopericardial congenital defects.
Lymphoma is the most common hepatic neoplasm, but is uncommon compared to metabolic and
inflammatory diseases of the liver. It often affects many organs including the spleen, kidneys and gastrointestinal
tract. Sonographically, lymphoma cannot be distinguished from other causes of hepatomegaly and tissue sampling is
necessary. Biliary cystadenoma is the most common benign neoplasm in the liver and ultrasonography is necessary
to recognize the many fluid-filled cavities and structures in the liver. However, these cannot be distinguished from
choangiocarcinoma.
Chole- and choledocholithiasis can produce gall bladder and bile duct mineralizations. Gallbladder stones
are diagnosed by their location in the right cranioventral abdomen. An enlarged gall bladder can look like a right-
sided ventral smoothly bordered soft tissue mass. Ultrasonography aids in localizing such findings to the biliary
system.
Biliary flukes may cause hepatomegaly, but the imaging findings are nonspecific unless fluid filled cysts are
identified sonographically.
Pancreas
Unless the pancreas enlarges to create a focal mass effect in the mid, left abdomen due to either pancreatitis
or pancreatic neoplasia (carcinoma, lymphoma), pancreatic disease is difficult at best to diagnose radiographically.
Spleen
Splenomegaly is not common in cats. Sedation, infection (hemobartonellosis), mast cell disease, anemia,
myeloproliferative disease and lymphoma are common etiologies. The spleen is typically not well visible except for
the head on lateral radiographs. The head can be identified in the most dorsal aspect of the cranial abdomen, ventral
to the spine and caudal to the fundus. The spleen is generally localized to the left abdomen in its entirety on VD
images.
The feline stomach spans the left side of the cranial abdomen to the midline where the pylorus is located and
the duodenum. This is most evident on VD images. Particular to the cat is the submucosal fat layer that separates
the soft tissue opaque serosal border from the similarly opaque rugal folds. This fat opaque later is best evident on
VD images and looks like a wagon wheel at the fundus.
The duodenum courses from the midline into the mid-abdomen and then turns medially to become the
Track B
jejunum. The jejunal segments are generally loosely arranged in the mid abdomen. However, in obese cats, the
jejunal can collect, almost like a ball, into the right side of the mid-abdomen and be mistaken for a linear foreign
body. The difference is that the gas patterns in those segments are tubular, not irregularly shaped or plicated as with
linear foreign material.
Radiography is mainly used to detect dilation of the gastrointestinal tract, either with gas, fluid, mineral or
granular opacities. Ultrasonography is necessary to diagnose inflammatory bowel disease and infiltrative infectious
and neoplastic diseases unless they create a mass that can be recognized radiographically. The only exception to
this is when there is severe thickening (>1-2 cm) of the stomach wall due to lymphoma where the stomach will be
enlarged radiographically and the mucosal interface with gas will look irregular. This finding is suspicious for a gastric
mass and sonography or an upper GI study with barium is indicated to confirm.
Hairballs are often associated with dilation of the stomach and delayed gastric emptying. They appear
granular or mineralized and heterogenous radiographically, similar to fabric.
Jejunal segments are approximately 12mm in diameter in normal cats, or two rib widths. The content must
be judged in relation to that of the stomach (postprandial or fasted). Gas content is typically minimal unless the cat is
aerophagic.
Megacolon is a persistent and irreversible increase in colon diameter which generally follows bouts of
obstipation. The diagnosis of obstipation vs. megacolon is very difficult radiographically and is generally diagnosed
clinically due to non-responsiveness to treatment for obstipation and presence of impacted feces. Radiographically
the fecal balls are more opaque and have a mineralized appearance when obstipated or with megacolon. After
deobstipation, the colon remains dilated and air-filled, due to its non-functional disorder. The colon diameter can be
compared to a ratio of the maximal diameter of the colon to the L5 length. A ratio of <1.28 is a strong indicator of a
normal colon (sensitivity 96%, specificity 87%). A value of >1.48 is a good indicator of megacolon (sensitivity 77%,
2
specificity 85%). Important in the radiographic examination is assessment of the pelvis for narrowing due to a
88
traumatic injury or congenital defect. Kittens with atresia ani or coli will have a very dilated colon and radiographically
there is usually no evidence of the gas or fecal filled colon progressing to the pelvic canal and rectum. Age, clinical
signs and radiography are usually diagnostic.
Colitis and infiltrative colonic wall disease is rarely evident radiographically unless a colonic mass is present.
Adrenal Glands
Mineralization of the normally sized adrenal glands is a common finding in adult and older cats. Adrenal
masses are located craniomedial to the kidneys and can be soft tissue opaque or partially mineralized.
Hyperaldosteronism has been associated with unilateral adrenal gland masses in cats and are usually best screened
3
for with ultrasonography if radiographs are negative. Enlarged adrenal glands can also occur with
4
hyperadrenocorticism, acromegaly, and hyperthyroidism.
Urinary Tract
The kidney length is about 2.5 X the length of L2 on the VD image. The right kidney is between L2-3, the left
slightly caudal to this. Some cats have the right kidney caudal to the left as a normal variant. Bilaterallly small kidneys
are classically due to chronic interstitial nephritis. Normally sized kidneys can be normal, however, some disease
such as acute renal injury (glomerulonephritis, ethylene glycol and interstitial nephritis) may appear normal.
Polycystic kidney disease often results in bilateral enlargement and the shape may be irregular or normal depending
on the extent of the cysts. A single enlarged kidney is either due to compensatory hypertrophy, neoplasia,
hydronephrosis or trauma. Bilateral enlargement can be due to obstruction at the lower urinary tract, lymphoma, FIP,
or perinephric pseudocysts.
Retroperitoneal soft tissue opacity on radiographs can represent effusion due to neoplasia and trauma.
Trauma can result in uro- or hemo-retroperitoneum. In these instances, and if the BUN and creatinine are elevated,
excretory urography is indicated. Ultrasonography can also be performed, but is really only a screening as the origin
of leakage of urine can be missed. If hemorrhage is present, ultrasonography helps to identify the kidneys as the
source.
Lymphoma will also cause a perinephric reaction that can appear as lack of distinction of the renal borders
sonographically.
Urolithiasis involving the pelvis and ureter in cats can be difficult to localize radiographically if intestinal
content is superimposed. Cats should have an enema prior to radiographic examination of the urinary tract for this
reason. Furthermore, ureteral calculi may come and go when multiple are present. When cats are diuresed
intravenously, the ureteral calculi can be flushed into the bladder. Therefore, repeat radiographs following fluid
therapy is important.
The urinary bladder is variable in size and location, being more cranial when full. Bladder neck avulsion can
occur in cats following severe trauma when the bladder is full. The cat may or may not have uroabdomen as the
bladder typically seals off at the neck and is displaced into the mid abdomen. A retrograde urethrogram is necessary
for the diagnosis.
Cystoliths are variable in size, shape, opacity, and number. If >3mm they are typically visible
Track B
radiographically. However, intestinal structures superimposed with the bladder can prevent their detection.
Compression radiography should be used in these instances to displace the bowel away from the bladder.
Bladder neoplasia is uncommon and requires contrast cystography or ultrasonography to diagnose, unless
they are dystrophically mineralized and can then be detected radiographically. The same can be said for cystits,
which also requires contrast procedures or sonography to further diagnose.
An enlarged bladder can be due to not wanting to urinate (in the cage, or hospital), obstruction, bladder neck
avulsion, neoplasia or neurogenic disease.
Genital tract
The normal genital tract is not visible radiographically. An enlarged uterus due to pyometra or mucometra
can be seen in breeding females and appears as a soft tissue tubular or cylindrical structure between the colon and
bladder on lateral images and along the body wall between the kidneys and pelvis on the VD image. Pregnancy prior
to fetal ossification will appear similarly, however. Ovarian abnormalities are extremely rare.
For pregnancy, the earliest fetal mineralization is visible radiographically at 38 days. At 49 days the
metacarpal bones are visible and at 52 days the phalanges and sternum can be detected. On day 53 the tympanic
bullae are evident. Fetal death is recognized by collapse of the cranium, intrauterine or fetal gas, or contracted fetal
posture.
References
1. Schwarz T, Morandi F, Gnudi G, Wisner E, Paterson C, Sullivan M, Johnston P: Nodular fat necrosis in the
feline and canine abdomen. Veterinary radiology & ultrasound : the official journal of the American College of
Veterinary Radiology and the International Veterinary Radiology Association 2000, 41:335-9.
89
2. Trevail T, Gunn-Moore D, Carrera I, Courcier E, Sullivan M: Radiographic diameter of the colon in normal
and constipated cats and in cats with megacolon. Veterinary radiology & ultrasound : the official journal of
the American College of Veterinary Radiology and the International Veterinary Radiology Association 2011,
52:516-20.
3. Combes A, Pey P, Paepe D, Rosenberg D, Daminet S, Putcuyps I, Bedu AS, Duchateau L, de Fornel-
Thibaud P, Benchekroun G, Saunders JH: Ultrasonographic appearance of adrenal glands in healthy and
sick cats. Journal of feline medicine and surgery 2013, 15:445-57.
4. Combes A, Vandermeulen E, Duchateau L, Peremans K, Daminet S, Saunders J: Ultrasonographic
measurements of adrenal glands in cats with hyperthyroidism. Veterinary radiology & ultrasound : the official
journal of the American College of Veterinary Radiology and the International Veterinary Radiology
Association 2012, 53:210-6.
NOTES:
Track B
90
Obstructed or Not? Get the Most from Abdominal Radiographs

Introduction
Radiography allows an overview of the abdomen while ultrasonography does not. A short cut to ultrasound in
a vomiting animal could lead to misdiagnosis of a disease that could be readily identified radiographically. Therefore,
radiography and ultrasonography should be considered complimentary diagnostic tests. Barium studies still have
importance in assessing animals with chronic gastrointestinal obstructions. The normal stomach and intestine in the
fasted cat is generally devoid of gas and fluid as cats are not aerophagic unless dyspneic or open mouth breathing,
in which case the disease is likely not abdominal in origin. The diameter of the jejunum is 12mm or two rib widths.
Radiographic signs of intestinal disease are usually dilatation, abnormal content or abnormal shape and distribution
of the segments.
Compression Radiography
Compression radiography is a valuable technique that is easy, inexpensive and very valuable in diagnosing
intestinal abnormalities and for eliminating superimposition of the urinary tract to identify urolithiasis. For intestinal
obstruction, common abnormalities are granular content in the lumen of solitary jejunal or duodenal segments. Linear
foreign bodies can be easily identified by their plicated or tortuous course. Compression radiography is used for the
abdomen to displace intestinal structures away from regions or organs of interest. Bowel is often superimposed with
other organs or even with itself and prevents us from being able to identify organs clearly. Examples are bowel
superimposed with the kidneys or bladder. Other examples are that intestines are superimposed with one another
and due to gas or other content, makes it difficult to investigate individual bowel segments for foreign bodies or
masses.
Technique
Left and right lateral recumbent and VD radiographs of the abdomen should be performed prior to
compression radiography. A wooden spoon with a long handle is used to gently press down on the abdomen in the
region of interest. The individual performing the procedure must follow radiation safety practices with lead apron,
thyroid shield and lead gloved hand.
Starting in lateral recumbency, the cranial and then caudal abdomen is compressed by placing the spoon on
the non-dependent side of the abdomen and exposing the radiography during compression. On the VD image, the
wooden spoon can be placed at the right or left side, cranially and caudally and pressed down toward the spine in the
region of interest (kidney, spleen, uterus region).
Track B
Ileus
Ileus is a failure of transport of intestinal contents and is typically recognized radiographically by the
presence of dilated bowel segments. Survey abdominal radiographs should always be performed in vomiting
animals. Ultrasound used alone in such instances does not allow a global view of the abdomen, is much more time-
consuming and non-gastrointestinal causes of clinical signs as well as any secondary abnormalities may be
overlooked. The radiographic appearance of ileus is dependent on its duration, location and degree of obstruction.
Acute or very proximal obstructions may show little intestinal dilation radiographically whereas chronic or more
distally located ones will show more generalized dilation of the small intestines. The two major types of ileus are
obstructive (mechanical) and functional. Obstructive ileus may be partial or complete.
Partial Obstructions
Partial obstructions tend to have a more chronic course of intermittent vomiting and diarrhea. Common
causes include foreign bodies and strictures. Fasted (>12 hours) or anorectic cats should not have small bowel
segments containing granular material resembling that of food content radiographically. Granular or more opaque
small bowel contents may be detected in partial obstructions. The intestines in such cases may be mildly dilated
proximal to the obstruction or may even be of normal diameter. Because partial obstructions may be more difficult to
diagnose radiographically than complete obstructions, complementary imaging procedures such as barium studies or
ultrasound are often necessary for the diagnosis. Repeat radiographic examination has great diagnostic value when
abnormal intestinal content is identified. If granular content is seen in the small intestine of an animal that is vomiting
or anorectic for more than 24 hours, obstruction should be considered likely. If the same finding of focal granular
luminal content is identified on follow-up radiographs, even if intestinal dilation is not evident, in a vomiting animal,
the chances of obstruction are high and sonography or exploratory surgery is indicated. Ultrasonography is highly
recommended in older animals to screen for intestinal masses prior to exploratory laparotomy.
91
Complete Obstructions
More severe dilation, usually with gas in the lumen, is seen in complete obstructions. The location of the
obstruction can be either intraluminal (foreign bodies), extraluminal (adhesions, herniation, intussusceptions), or
intramural (neoplastic wall infiltrations, granulomas). Dilation is seen proximal to the site of obstruction and the
segments distal to it usually appear empty and contracted. Due to this, the jejunal segments appear to have many
varied diameters, some very dilated, others empty or small. This is called a “mixed population”. This is due to the
continued peristaltic activity in the distal segments. The dilated segments are often referred to as “sentinel loops”.
Proximal duodenal or pyloric obstructions may show no radiographic abnormalities. Twenty-four hours following a
gastric outflow obstruction, the animal has vomited out the intestinal contents and the intestinal content moves to the
colon. Abdominal radiographs may show no abnormalities or gastric distention. Moreover, the entire gastrointestinal
tract may actually appear completely empty after some hours due to recurrent vomiting. The most common difficulty
in diagnosing complete obstructions is in trying to differentiate small from large bowel when the colon is dilated and
especially gas filled. It is recommended in such instances to perform a small volume barium enema in order to
identify the colon and distinguish it from the small intestinal segments that may or may not be dilated. When the
abdomen appears normal radiographically in a vomiting animal, either a barium study or an ultrasound examination
should be the next diagnostic procedure.
Functional Ileus
Another form of ileus that can be detected is a generalized and uniform mild intestinal dilation due to lack of
peristaltic activity. This is known as adynamic, functional or paralytic ileus and results from an inhibition of bowel
motility. Functional ileus results in obstruction since the intestinal contents pool in the dependent areas of the
gastrointestinal tract. Radiographically the gastrointestinal tract appears mildly dilated, can have a mixed content with
some gas- and some fluid-filled intestines and colon have generalized fluid or gas filling. The distribution of the
intestines in the abdomen is regular. Gas is often present in the stomach. Typically, granular ingesta in the stomach
and bowel is not identified. The intestines appear to have a uniform diameter. Animals with this pattern typically have
clinical signs of both vomiting and diarrhea. Such an adynamic intestinal pattern can be due to the administration of
pharmaceutical agents such as parasympatholytics and sedatives. Other causes are peritonitis, blunt abdominal
trauma, electrolyte imbalance and enteritis of various causes.
Complicated ileus
Complicated forms of ileus include bowel perforation with peritonitis, free air in the abdominal cavity, bowel
ischemia due to thromboembolism, intussusception, or volvulus at the root of the mesentery. Linear foreign bodies
can also lead to a complicated form of ileus. The presence of pneumoperitoneum together with abdominal effusion
on an abdominal radiograph should alert the clinician that bowel perforation has occurred. The detection of free
intraabdominal air may require the use of ventrodorsal horizontal beam radiography with the patient in left lateral
recumbency. Free gas can be detected just under the right abdominal wall and lateral to the duodenum. Volvulus or
mesenteric thromboembolism is recognized by the presence of generalized, severely dilated and air-filled jejunal
segments. Linear foreign bodies produce characteristic changes on abdominal radiographs in cats. The small
Track B
intestinal loops appear convoluted and gathered or clumped together at one site, usually in the mid-right abdomen
and intraluminal gas bubbles appear asymmetrical and irregularly shaped.
Complications of Obstructions
Gastrointestinal perforation affects the peritoneum. Due to this, radiographic and sonographic features of
perforation are characteristic of peritoneal disease. Clinical signs include fever, dyspnea, inappetence, vomiting,
abdominal pain and possible diarrhea. Causes of perforation of the gastrointestinal tract include foreign body
perforation, perforating ulcer either due to benign or malignant diseases, non-steroidal anti-inflammatory therapy,
bullet wound perforation, surgical dehiscence, intussusception, gastric dilatation volvulus.
Pneumoperitoneum
Free gas in the peritoneal space usually occurs with a perforated intestinal wall. However, chronic erosions
of the wall due to neoplasm or chronic foreign body may be walled off and gas may not be evident radiographically.
Free gas in the absence of recent laparotomy, trauma or abdominal perforation usually indicates intestinal perforation
as the source. Presence of free air is in most all cases a surgical emergency. Rupture of the stomach usually leads
to large amounts of air while if in the small intestine, the amount is smaller. Radiographic signs of pneumoperitoneum
include loss of serosal detail as well as increased visualization of serosal margins due to outlining with gas.
Horizontal beam radiography is indicated for suspicion of free gas when only small volumes are present. Free
peritoneal air will tend to accumulate adjacent to the diaphragm, have triangular shapes, and may collect adjacent to
the ribs and between the liver lobes. Large volumes of free gas can be more difficult to recognize radiographically
than small volumes as they are so generalized over the abdomen they go unnoticed. The loss of serosal detail in the
presence of free air is usually due to peritonitis secondary to the perforation. Radiographically, unless an intestinal
mass or a radiolucent foreign body is identified, the site of intestinal perforation often is not identifiable.
92
Use of the Upper GI study
An upper GI study can be performed in vomiting cats, but should be performed only after fasting, full set of
abdominal images and compression study are inconclusive. Ultrasonography is also warranted prior to the upper GI
study, but this is at the discretion and experience of the veterinarian. The upper GI will aid in identifying an
obstruction due to stenosis, extramural compression as well as intraluminal radiolucent foreign body. The best
indications are vomiting with a negative radiograph, detection of radiolucent foreign body or stricture, detection of a
pyloric outflow obstruction, poor visualization of the abdominal organs and need to identify the stomach and small
intestines. Barium should not be administered in cats with peritoneal effusion and painful abdomen when an intestinal
perforation is possible. Those animals require an abdominal ultrasound or abdominocentesis to rule out peritonitis
first. To perform the examination, the animal must be fasted and confirmed with survey radiographs. An enema
should be given. 30% Barium sulfate suspension at 10ml/kg body weight should be administered orally. Lateral and
VD radiographs should be performed at 0, 15, 30 and 45 minutes. Additional views (R and L lateral and DV) can be
performed also. The most common mistakes of the barium study are too few images, too little contrast and poor
radiographic technique. The likelihood of a suspicious area being a real lesion is increased if it is visible n multiple
images at multiple time points. Lesions are detected as filling defects either within the contrast pool (luminal) or mural
(irregular contrast borders), or extraluminal (narrowed area with smooth contrast borders).
At 1 hour post barium administration, contrast should start to fill the colon in a cat with normal transit time and this
would also make a complete obstruction very unlikely.
NOTES:
Track B
93
NOTES:
Track B
94
Improve Your Interpretation of Radiographic Pulmonary Patterns in the Cat

Introduction
After performing a systematic review of the entire thorax, careful scrutiny of the lung can be one of the most
challenging parts of analyzing a thoracic radiograph. Using a practical approach to determine if the lung is abnormal
or not then making a decision on whether the air space, the airway is important. Also important to realize is that most
all diseases cross the borders of all parts of the lung.
Are Patterns Important?

The principles of the pulmonary pattern are important, but a lot of stress can be associated with trying to
determine the correct pattern so that one can make the correct diagnosis. A better approach is to determine if the
main opacity of the lung is in the air space or the airway. Most diseases are in one or the other. In between is the
interstitium and the interstitium is often involved anyway. Pure interstitial disease is really only sure when structured
nodules are present. Unstructured interstitial disease is often very difficult to diagnose as a sole abnormality.
Determining if disease is in the air space or airway is the best way to set a course of action. By creating a best
course of action based on which compartment is most affected and then re-assessing the radiograph at an
appropriate time point following treatment is good medical practice.
The Normal Lung

The normal feline lung is rather lucent with few linear markings, mostly visible centrally. The periphery of the
lung is almost devoid of vascular markings. Thinner body condition makes the lung look hyperlucent and bronchial
and vascular markings may be more visible in the periphery. The opposite is true for obesity where the lung has a
hazy interstitial appearance due to the opacity of superimposed fat. Both situations make the lung challenging to
assess and emphasis on the clinical signs is important for interpretation.
Air Space Disease

The alveoli are filled with air and this allows the vessels and bronchial structures to be sharply marginated
and therefore well visible. These structures are extremely small in the periphery of the feline lung and this is the
reason the periphery is so lucent. When an increased opacity is identified, the first duty is to determine if it is effacing
the border of any of soft tissue structure. The margins of the heart, pulmonary vessels, caudal vena cava and
diaphragm should be scrutinized first. If any one or more of those margins are blurred, the pulmonary opacity is likely
in the air space: it replaces air with soft tissue and the air no longer outlines soft tissue structures, making them less
visible.
Track B
Air space disease may be lobar. If the right middle lobe is homogeneously soft tissue opaque and is the only
lobe affected, then atelectasis due to lower airway disease is the likely cause. Aspiration pneumonia is rare in cats
and would only be diagnosed if there is a clinical history of vomiting or regurgitation. If the clinical history fits with best
with increased respiratory rate and wheezing, then atelectasis is the diagnosis.
Other radiographic features of air space disease are air bronchograms, consolidated lobes with lobar sign,
and patchy opacities that silhouette borders of vessels, heart and diaphragmatic contours. Lobar consolidation is
when the entire lobe is homogenously soft tissue opaque and not reduced in volume, with our without air
bronchograms. It is usually due to pneumonia, neoplasia or contusion. Atelectasis is collapse of the lobe due to
pleural space disease or bronchial obstruction. The lobe is opaque and there is a decreased volume, and mediastinal
shift of the heart to the affected lobe
Common disease categories causing air space disease are pneumonia, edema, hemorrhage, atelectasis,
infection, allergic inflammatory disease, and some neoplasia.
Multifocal, ill defined, patchy soft tissue opacities that obscure the airspace and vessels in their surrounding
are often due to infection or edema. Fungal pneumonia and cardiogenic edema are the most common of these, but
neoplasia and contusions also have this appearance. Histoplasmosis can also have a patchy ill-defined mixed or
airspace pattern as can cardiogenic edema. Other causes of infectious pneumonia are mycobacterial, cryptococcal,
1
blastomycosis, aspirgillosis, toxoplasmosis, paragonimus and aleurostrongylus. Lipid pneumonia is less common
but consistently seen in cats. Radiographic abnormalities in aleurostrongylus infection are dependent on severity
and duration of infection. Early changes of bronchial thickening and small, poorly defined nodules progress to a
generalized alveolar pattern in severe cases. After partial resolution of the alveolar pattern, an unstructured, patchy
interstitial pattern develops.
95
Airway Disease
Lower airway disease can appear radiographically normal or have varying severities of airway pattern.
Tracing the trachea to the carina and then tracing each main bronchus of each lobe should be performed. Two-thirds
of the way out from the carina, the visualization of the bronchial walls and vessels should slowly disappear. If larger
numbers of branching structures are visible, then an airway pattern is present. However, clinical signs are not always
present. The clinical signs of airway disease may wax and wane, but chronic airway patterns are persistent on
thoracic radiographs, regardless of clinical activity. This is where reader bias can sway the importance placed upon
2
the presence of an airway pattern, or even lead the reader away from other abnormalities due to tunnel vision.
Airway disease is usually due to allergic airway disease, asthma and heartworm infection. A recent study confirmed
that the most common radiographic abnormality is a bronchial pattern, but an unstructured interstitial pattern can be
2
present in many cats. More than half of the cats in that study had lung hyperinflation also. Bronchiectasis can be
identified in a smaller number of cats. Right middle lobar atelectasis can be seen, as can small nodules throughout
the lung and represent mucous plugs with granuloma formation.
Severe inflammatory lower airway disease can lead to hyperinflation with a flattened diaphragm. The
bronchial pattern can be mixed with small nodules due to mucous plugging and exudates.
Interstitial Lung Disease

Primary Neoplasia
Primary pulmonary neoplasia is relatively uncommon in cats and generally has a poor prognosis.
Radiographically it is typically a solitary or multiple masses, or, a disseminated lung pattern or lobar consolidation
that looks like pneumonia. Adenocarcinoma may be come cavitated. Bronchoalveolar cell carcinomas and squamous
cell carcinoma are usually diffuse in the lung. Most pulmonary tumors are in the caudal lobes. Adenocarcinoma is
reported as the predominant tumor type, but shares many features with less common tumor types. Prevalence of
3
suspected intrapulmonary metastasis was higher than in previous radiographic studies of cats with lung tumors.
Metastatic neoplasia
Metastatic neoplasia generally present as multifocal small round soft tissue pulmonary nodules. In cats, lung-
digit syndrome is an unusual pattern of metastasis that is seen with various types of primary lung tumors, particularly
bronchial and bronchioalveolar adenocarcinoma. Tumor metastases are found at atypical sites, notably the distal
phalanges of the limbs; the weight bearing digits are most frequently affected, and multiple-digit and multiple-limb
4
involvement is common.
Pulmonary Fibrosis
Pulmonary fibrosis is a progressive fatal interstitial lung disease that is often idiopathic, occurs in multiple
species, and may be caused by a number of inciting factors. A recent study of nine cats showed that all patients had
a broad range of radiographic characteristics that included broncho-interstitial pattern, alveolar pattern, pulmonary
5
masses, pulmonary bullae, pleural effusion, and cardiomegaly. Cats in that study with echocardiographic studies
had characteristics that included right ventricular dilation and hypertrophy and pulmonary arterial hypertension
Track B
interpreted to be secondary to primary lung disease. Cats with pulmonary fibrosis have highly variable radiographic
characteristics and that these characteristics may mimic other diseases such as asthma, pneumonia, pulmonary
5
edema, or neoplasia.
Vascular Disease
Heartworm disease can cause enlarged pulmonary arteries. However, the pulmonary findings may also be
rather unremarkable in infected cats. An airway pattern is often present in most cases as well. Cardiac abnormalities
are not typical.
References
1. Dennler M, Bass DA, Gutierrez-Crespo B, Schnyder M, Guscetti F, Di Cesare A, Deplazes P, Kircher PR,
Glaus TM: Thoracic computed tomography, angiographic computed tomography, and pathology findings in
six cats experimentally infected with Aelurostrongylus abstrusus. Veterinary radiology & ultrasound : the
official journal of the American College of Veterinary Radiology and the International Veterinary Radiology
Association 2013, 54:459-69.
2. Gadbois J, d'Anjou MA, Dunn M, Alexander K, Beauregard G, D'Astous J, De Carufel M, Breton L,
Beauchamp G: Radiographic abnormalities in cats with feline bronchial disease and intra- and interobserver
variability in radiographic interpretation: 40 cases (1999-2006). Journal of the American Veterinary Medical
Association 2009, 234:367-75.
3. Aarsvold S, Reetz JA, Reichle JK, Jones ID, Lamb CR, Evola MG, Keyerleber MA, Marolf AJ: Computed
tomographic findings in 57 cats with primary pulmonary neoplasia. Veterinary radiology & ultrasound : the
96
4. Goldfinch N, Argyle DJ: Feline lung-digit syndrome: unusual metastatic patterns of primary lung tumours in
cats. Journal of feline medicine and surgery 2012, 14:202-8.
5. Evola MG, Edmondson EF, Reichle JK, Biller DS, Mitchell CW, Valdes-Martinez A: Radiographic and
histopathologic characteristics of pulmonary fibrosis in nine cats. Veterinary radiology & ultrasound : the
Association 2014, 55:133-40.
NOTES:
Track B
97
NOTES:
Track B
98
Radiographic Interpretation of Heart Disease in Cats

Introduction
Diagnosing heart disease in cats is challenging since heart murmurs are not always present and or if they do
they are not always associated with functional or structural changes in the heart. Clinical signs can be nonspecific.
Furthermore, some of the most common myocardial diseases may not result in size or shape changes
radiographically. However, thoracic radiography assessment for cardiac disease is important and includes the heart
size and shape, the size and shape of the pulmonary arteries and veins as well as the lung opacity. Lateral and
ventrodorsal views of the thorax are adequate for assessing a cat for cardiac disease.
Heart Size
The width of the heart on the lateral image should be no more than 2-2.5 intercostal spaces. The vertebral
heart score can alternatively be used and is useful as a quantitative measure of size when assessing serial
1,2
radiographs over the course of disease and treatment.
To perform the vertebral heart score, measure the distance between the ventral aspect of the carina and
cardiac apex using the digital calipers of the imaging software or a use a piece of paper on analog film images. Then,
take a second measurement perpendicular to the first at the widest point of the heart. Compare the length of these
two lines with the thoracic vertebral length starting at the cranial endplate of Th4. Count the vertebral bodies that
correspond to the length of the two lines and add them. This is the VHS. Normal values are 7.5 +/- 0.3. The width of
2
the heart on the VD view is 3.4 vertebral lengths as a rule of thumb. VHS has been used in cats to assess the
hearts in obese animals, those with cardiogenic edema for diagnosing heartworm disease and for differentiating
congestive heart failure from other causes of dyspnea. A recent study looked at the use of VHS in 105 cats to
determine if it could differentiate cats with and without cardiac disease and showed that the lateral view VHS at the
cut-off of 7.9v had moderate accuracy in distinguishing cats with left sided cardiac disease and moderate-to-severe
3
left atrial enlargement from healthy cats. Radiographic indices were also only moderately accurate in predicting
different degrees of left atrial enlargement in cats with left sided cardiac disease. This is likely due to the fact that the
left atrium is superimposed with the heart on lateral and ventrodorsal images, making its degree of enlargement more
difficult to detect. Furthermore, and perhaps most important to know, most feline cardiac diseases are
cardiomyopathies that are not associated with left ventricular enlargement, therefore, underestimated on
radiographs. In cats, the VHS is more a representation of the left atrial size and therefore, cats with moderate to
severe left atrial enlargement are easy to distinguish from healthy cats using the VHS 7.9 cutoff. Summary:
radiographic indices are reasonably specific, but less sensitive predictors of cardiac enlargement in cats
with heart disorders. Moreover, the indices cannot accurately differentiate between healthy cats and those with
Track B
cardiac disease.
Heart Shape
Conflicting information has been published regarding the cause of a valentine-shaped cardiac silhouette in
dorsoventral or ventrodorsal thoracic radiographs in cats. A study of 81 cats showed a strong positive correlation (P <
4
0.001) between echocardiographic left atrial size and severity of radiographic valentine shape. There was no effect
of echocardiographic right atrial size on the severity of valentine shape, except when concurrent with severe left atrial
enlargement. In this situation, right atrial enlargement increased the likelihood of observing a severe valentine shape.
There was no effect of right atrial enlargement on the shape of the cardiac silhouette when left atrial enlargement
was absent or only mild to moderate. However, there was no correlation between the category of final diagnosis of
cardiac disease and the severity of valentine shape. Findings from the study supported the hypothesis that a
valentine-shaped cardiac silhouette in radiographs is due primarily to left atrial enlargement in cats, with right atrial
enlargement only impacting the shape if concurrent with severe left atrial enlargement. Therefore, the term “biatrial”
enlargement is actually incorrect.
Cranial Lobe Vascular Size

The right cranial lobar artery should be 0.5-1.0 times the proximal third of the fourth rib measured at the level
th
of the 4 rib on lateral radiographs. The cranial lobar vein should be 0.2cm in diameter at the same point of
measurement. The caudal lobar vessel size is measured on the VD image and the artery and vein should be about
th
the same size and no greater than the width of the 9 rib where they cross. The upper limit of 1.6 times the width of
th
the 9 rib is used in cats for the cut off for the lobar arteries in cats with heartworm disease. These are only general
guidelines and normal sized vessels do not exclude the presence cardiac disease or heart failure.
99
Radiographic Signs of Left-sided Heart Failure in the Cat
Left-sided Heart Failure
The presence of lung opacities in a cat with suspected heart disease or signs of cardiomegaly increases the
likelihood of cardiogenic pulmonary edema. The opacities can range from interstitial to severe air space localizations
and can be perihilar or multifocal. A patchy uneven distribution is common in cats.
Pleural effusion in the cat can be a sign of left heart failure and the pathophysiology is poorly understood and
controversial in the literature. Anatomical drainage of the pleural via the thoracic duct is the current theory.
A recent study has shown that a normal left atrial size on thoracic radiographs does not rule out the presence
5
of left-sided congestive heart failure in cats with clinical signs of respiratory distress. Approximately half of the cats in
failure in this study had left atrial enlargement and the other half did not.
Right-sided Heart Failure

Right-sided heart failure rarely leads to pleural effusion in cats. More commonly, peritoneal effusion,
hepatomegaly and a widened caudal vena cava can be identified as well as pericardial effusion.
Congenital Feline Cardiac Diseases

The most common congenital cardiac diseases are VSD, PDA, ASD and mitral and tricuspid dysplasia and
these conditions lead to volume overload due to left to right shunting. Radiographically they appear as cardiac
enlargement and enlarged vessels. Mitral and tricuspid dysplasia rarely results in radiographic abnormalities,
however. PDA radiographic features are generalized cardiomegaly and pulmonary vascular dilation, which makes the
lung appear diffusely more opaque as well. A recent case report described an adult cat with right-sided congestive
heart failure due to PDA due to pulmonary hypertension. Cats can develop pulmonary hypertension and heart failure
6
due to left to right PDA even as adults and can be treated surgically.
Pressure overload disease is usually due to dynamic subaortic stenosis in cats and all other defects are
uncommon. In young cats that are cyanotic, tetralogy of Fallot and endocardial cushion defects are most common,
although both are uncommon in general. Right to left shunting disease generally results in either a normal heart or
right-sided enlargement and a hyperlucent lung due to the right to left shunting that occurs, drawing blood away from
the pulmonary vasculature.
Acquired Feline Myocardial Diseases

Hypertrophic Cardiomyopathy
Feline hypertrophic cardiomyopathy leads to concentric hypertrophy, which can be focal or asymmetrical and
leads to diastolic heart failure and progressive left atrial enlargement. Left sided increased filling pressures lead to
left atrial enlargement and pulmonary venous distension, the main abnormalities found on thoracic radiographs.
Pulmonary edema can affect any region of the lung and is often a patchy air space, interstitial or mixed abnormality.
There are many forms of myocardial disease in cats, however radiography cannot distinguish them. Enlargement of
the left atrium often leads to the valentine shape on the VD image, which has often been misnamed as “bi-atrial”
enlargement. Left atrial enlargement is recognized as widening of the heart on the VD image and a “reniform” shape
Track B
on the lateral image. A recent study showed that echocardiographic presence of right atrial enlargement has no
effect on the shape of the cardiac silhouette in cats with HCM and when left atrial size was normal or mild to
moderately enlarged. However, if right atrial enlargement was present it only had an effect on the shape of the heart
4
if severe left atrial enlargement was present. Therefore, the evidence in this study supports that the valentine
shaped heart is principally due to left atrial enlargement.
Restrictive cardiomyopathy appears similarly and cannot be differentiated form HCM radiographically.
Thyroid toxicosis can also result in hypertrophic cardiomyopathy that appears similar to the idiopathic form
radiographically.
Echocardiography is necessary to differentiate hypertrophic obstructive cardiomyopathy with dynamic left
ventricular outflow obstruction, restrictive cardiomyopathy, unclassified cardiomyopathy, dilated cardiomyopathy, and
feline arrhythmogenic right ventricular cardiomyopathy. Except for ARVC, these diseases all appear similarly
radiographically, much like HCM. ARVC will generally show an enlarged liver and peritoneal effusion with or without
cardiac enlargement.
Pericardial Disease
Pericardial Effusion
Pericardial effusion is due to congestive heart failure, feline infectious peritonitis and lymphoma.
Radiographically the heart will have globoid enlargement with very sharp margins compared to a normal cat. The
diagnosis is generally confirmed clinically (muffled heart sounds) and with echocardiography.
Peritoneopericardial Diaphragmatic Hernia (PPDH)

Radiographically, PPDH appears as cardiac enlargement and silhouetting between it and the diaphragmatic
cupola. Various opacities of the heart may occur depending on what abdominal structures have entered the
100
pericardial sac. Fat (falciform fat), soft tissue (liver, spleen) and tubular gas (intestines) opacities are possible as well
as sternal defects. Abdominal radiographs should be performed in suspected PPDH, especially when the heart is
severely enlarged and the stomach or falciform fat is not visible in the cranial abdomen. Cats can be asymptomatic
for a long time and PPDH can be an incidental finding while screening the thorax for other disease such as for
metastatic disease. Because of this, the presence of the PPDH radiographically does not necessarily mean it is the
cause of the presenting complaints and the veterinarian should be careful to not be led astray by its presence.
Myocardial Neoplasia
Lymphoma is the most common cardiac neoplasm. It also affects the pericardium and pericardiocentesis can
be diagnostic on cytology. Thickening of the myocardium can appear similar to other myocardial diseases and for
that reason can be misdiagnosed.
Heartworm Disease
The most common radiographic sign of disease is enlargement of the pulmonary arteries. They are typically
th
greater than 1.6 times the width of the 9 rib on the VD image. Additionally, they can be tortuous in their course, but
this is not always present. The lungs generally have a bronchial or mixed pattern with interstitial haziness. As for
cardiac size, it has been shown that cats with heartworm disease have a greater vertebral heart score (mean 8.64 +/-
7
0.17v) than healthy cats (<7.9v) and the width of the caudal vena cava was also found to be greater.
References
1. Litster AL, Buchanan JW: Vertebral scale system to measure heart size in radiographs of cats. Journal of the
American Veterinary Medical Association 2000, 216:210-4.
2. Ghadiri A, Avizeh R, Rasekh A, Yadegari A: Radiographic measurement of vertebral heart size in healthy
stray cats. Journal of feline medicine and surgery 2008, 10:61-5.
3. Guglielmini C, Baron Toaldo M, Poser H, Menciotti G, Cipone M, Cordella A, Contiero B, Diana A: Diagnostic
accuracy of the vertebral heart score and other radiographic indices in the detection of cardiac enlargement
in cats with different cardiac disorders. Journal of feline medicine and surgery 2014, 16:812-25.
4. Oura TJ, Young AN, Keene BW, Robertson ID, Jennings DE, Thrall DE: A valentine-shaped cardiac
silhouette in feline thoracic radiographs is primarily due to left atrial enlargement. Veterinary radiology &
ultrasound : the official journal of the American College of Veterinary Radiology and the International
Veterinary Radiology Association 2015, 56:245-50.
5. Schober KE, Wetli E, Drost WT: Radiographic and echocardiographic assessment of left atrial size in 100
cats with acute left-sided congestive heart failure. Veterinary radiology & ultrasound : the official journal of
the American College of Veterinary Radiology and the International Veterinary Radiology Association 2014,
55:359-67.
6. Novo-Matos J, Hurter K, Bektas R, Grest P, Glaus T: Patent ductus arteriosus in an adult cat with pulmonary
hypertension and right-sided congestive heart failure: hemodynamic evaluation and clinical outcome
following ductal closure. Journal of veterinary cardiology : the official journal of the European Society of
Track B
Veterinary Cardiology 2014, 16:197-203.
7. Litster A, Atkins C, Atwell R, Buchanan J: Radiographic cardiac size in cats and dogs with heartworm
disease compared with reference values using the vertebral heart scale method: 53 cases. Journal of
veterinary cardiology : the official journal of the European Society of Veterinary Cardiology 2005, 7:33-40.
NOTES:
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NOTES:
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102
Special Sonographic Features of the Feline Abdomen

Introduction
Sonographic examination of the feline abdomen should always be approached systematically. The
sonographer should maintain an organized approach to be used on every examination. I am not a fan of single organ
examinations and feel that taking shortcuts to only look at one organ will often lead to losing the big picture on many
diseases. Furthermore, an abdominal radiograph should always be performed prior to sonography in most all
instances. The radiograph provides an overview that is invaluable. Radioopaque foreign material can even be missed
during sonography. Therefore, taking shortcuts directly to sonography can result in lack of complete understanding of
a disease process.
Hepatobiliary Organs
The feline liver can sometimes be tricky to examine in obese cats. A common error is to mistake the falciform
fat for the liver, commonly seen in beginning sonographers. The falciform fat has a structured appearance that
resembles the liver. Careful attention to the hyperechoic liver capsule helps the sonographer to see the separation
between the fat and the liver. Comparatively, the falciform fat should be hyperechoic compared to the liver. The
spleen is generally farther away from the liver anatomically and it can be difficult to have them next to each other for
an echogenicity comparison. I often make a split image with the liver and spleen side by side on two separate images
to compare their echogenicity. This is important, as an increase in liver echogenicity is one of the most common
signs of hepatopathy.
The use of ultrasound and ultrasound-guided tissue sampling has now surpassed the use of survey
radiography for the diagnosis of many liver diseases due to its broad availability and greater sensitivity. Diffuse
parenchymal disease generally affects all lobes and may appear normal, iso- or hyperechoic. Examples include:
cholangiohepatitis, diffuse prenodular (early) metastatic carcinoma or sarcoma, round cell neoplasia (lymphoma,
mast cell disease and histiocytic sarcoma), patchy or diffuse fatty infiltration, vacuolar hepatopathy, storage diseases
(amyloidosis, copper), toxic hepatopathy and early degenerative changes associated with micronodular hyperplasia
and fibrosis. The overall accuracy of ultrasound as the sole criterion for discriminating among the categories of
diffuse liver disease is <60% in cats. It is generally not possible to make a final diagnosis based on the combination
of sonographic findings and biochemical and hematological data with diffuse liver disease. Tissue sampling,
preferably for histological examination, is required for a definitive diagnosis in most instances, even if the liver
appears sonographically normal.
Vacuolar changes in the liver associated with lipidosis usually cause hepatomegaly in conjunction with
diffuse hyperechogenicity and rounded borders. Inflammatory disease can be associated with diffuse
Track B
hypoechogenicity. If acute hepatitis or cholangiohepatitis is present, the liver may appear to have high contrast; a
hypoechoic parenchyma with pronounced hyperechogenicity of the portal veins. Chronic inflammation of the liver will
usually result in hyperechoic or mixed echogenicities. When fibrosis or cirrhosis is present, the liver may be smaller
and hyperechoic. If nodular hyperplasia develops such as with vacuolar hepatopathy, the liver may appear more
heterogeneous and nodular such as in neoplastic disease. Other differentials for this pattern include amyloidosis in
cats.
Focal or multifocal changes in the liver parenchyma are easier to identify sonographically than diffuse
changes. Hypo-, hyper- and anechoic lesions are easy to identify as they contrast better with the surrounding
parenchyma. Therefore, cystic lesions are the easiest to detect, even when very small.
Anechoic cavitary structures in the liver can be due to necrosis, neoplasms or cysts. Cysts structures
generally have sharply defined borders, can be round or irregular in shape and may even contain hyperechoic septa
within them. Causes include congenital cysts, due to cavitations following trauma, biliary pseudocysts or parasitism.
1
Unfortunately, biliary cystadenomas and cystadenocarcinomas may appear similarly.
Neoplastic disease of the liver may manifest as diffuse, multifocal or focal disease sonographically. Diffuse
disease is usually due to round-cell neoplasia. Lymphoma, histiocytic sarcoma and mast cell tumor are the most
common neoplasms that may lead to diffuse changes that remain sonographically undetectable. Carcinomas tend to
be diffusely spread throughout the liver and often lead to a mixed pattern.
Malignant nodules have a highly varied appearance and size. They may appear as hypo- or hyperechoic
nodules, target lesions or heterogenous ill-defined nodules. Hypoechoic nodules can be due to nodular hyperplasia,
metastases, lymphoma, histiocytic sarcoma, primary neoplasia, necrosis, hematomas and abscesses. For this
reason, tissue sampling is critical to a definitive diagnosis and the presence of hepatic nodules is not synonymous
with malignancy. Hepatic target lesions have a positive predictive value for malignancy of 74% and emphasizes the
fact that histological type cannot be predicted by the presence of target lesions.
103
Hepatic abcessation occurs rarely in small animals and may appear similar to a primary tumor, granuloma or
hematoma due to their highly variable sonographic features. Sonographically, they may be round to irregular in
shape with either a hypoechoic central region or of mixed echogenicity. Reverberation artifacts may be detected due
to gas accumulations within the necrotic tissue. Focal peritonitis may be seen with abcessation and include free
peritoneal fluid and focal hyperechoic mesentery.
The feline gall bladder is typically ovoid but can be bi-lobed. The cystic duct is highly tortuous in the cat. The
gallbladder wall is approximately 1mm thick in the cat and the bile is anechoic. Gallbladder wall thickening and
2
sludge are indicative of gallbladder disease. Cholecystocentesis is helpful in these instances for performing
bacteriology and cytology. Extrahepatic bile duct obstruction often results in dilation of the common bile duct,
between the porta hepatis and the major duodenal papilla. The papilla is fairly easy to identify in cats as it is round
and echogenic, located at the wall of the cranial duodenum, a short distance from the pylorus. The common bile duct
is easily visible in most cats as a thin anechoic tube ventral to the portal vein, another large and easy to identify
3
structure in the cat. Only about half of cats with obstructive biliary disease have a dilated gallbladder. The bile duct
should be traced and observed for wall thickening, intraluminal echogenic or hyperechoic shadowing material and for
papillary masses. Inflammatory disease of the papilla can be as obstructive as a cholelith.
Spleen
The spleen is small in healthy cats and is very laterally located in the left cranial abdomen. Sometimes it is
necessary to scan intercostally to find the spleen. Usually if one cannot find the spleen, it is small and dorsal and the
sonographer needs to strive to find it intercostally.
Splenomegaly in the cat can be caused by extramedullary hematopoiesis, hyperplasia, chronic inflammation,
immune mediated disease, neoplasia, and infectious organisms. Lymphoma is by far the most common neoplasm
affecting the spleen. Mast cell tumor and histiocytic sarcoma are also possible and often cause splenomegaly.
Histoplasmosis is a systemic fungal infection that affects many organs in the cat, including the spleen.
4
Sonographically it appears enlarged and diffusely hypoechoic and in some instances can be mottled.
The Stomach
5
A recent report describes the appearance of the caudal esophagus and cardia in cats as well as the pylorus.
A convex probe is best for examining details of the gastrointestinal tract in the cranial abdomen due to the smaller
size of the probe footprint.
Gastritis is very difficult to diagnose sonographically and there are few specific signs. Cats rarely get ulcers
unless induced by an overdose or chronic use of anti-inflammatory agents. Ulcers can lead to a focal wall thickening
that, if not masked by gas and ingesta, can be identified sonographically. Linear foreign bodies anchored at the
tongue may also cause bunching up of the stomach in addition to the jejunum. Hair balls are identified as a
heterogenous structure with gas reverberations and shadowing.
The gastric wall in the cat is usually about 3mm thick. Thickening with loss of layering is mainly due to
neoplasia. Gastric neoplasia can only be identified with sonography approximately 50% of the time compared with
Track B
6
endoscopy. Gastric lymphoma often leads to a transmural, hypoechoic wall thickening, often diffuse or within a large
section of the stomach.
The Duodenum
The duodenum is very midline and to find it sonographically, one must focus on the porta hepatis, identify the
stomach and trace it rightward and the pylorus and duodenum will be easily visible. Continuing, trace the duodenum
along its short length and notice the small papilla at its cranial end for entrance of the common bile duct and
pancreatic duct.
The Jejunum
Randomly distribute, 2-3mm in thickness with distinct five wall layers. The most common abnormality of the
7
small intestine is muscularis thickening seen in both inflammatory bowel disease and lymphoma. Linear foreign
bodies have a specific appearance where the bowel is plicated together and often a thin hyperechoic band is evident
pulling them together.
The ICCJ (Ileocecocolic junction)

The feline cecum is a small bulbous organ having a subtle curvature (concave side toward the ileum),
located in the right abdomen ventral to the descending duodenum. A small constriction demarcates the transition with
the colon and the ileum enters the ascending colon obliquely from the left, just distal to the cecocolic transition. The
position of the ileum relative to the cecum is fixed by the presence of the ligamentum ileocecalis, in which the
ileocecal lymph nodes are located. These lymph nodes are usually paired and can be found along the concavity of
8
the cecum. The ascending mesocolon contains one to five colonic lymph nodes.
104
Peritoneum and Lymph Nodes
Steatitis is inflammation of fat and appears as hyperchoic nodular infiltration that can produce shadowing
sonographically. The appearance of carcinomatosis on the other hand is that of hypoechoic nodular infiltration of the
mesentery. Enlarged lymph nodes can be detected sonographically when they are not large enough to be evident
radiographically. However, enlarged lymph nodes in cats can be due to reactive hyperplasia as well as neoplasia,
with no one feature specific for either. Sonographic features do not distinguish reactivity, infection from neoplasm.
Furthermore, ultrasound-guided tissue sampling of small structures like lymph nodes is increasingly performed.
However, lymph node cytology can be fraught with difficulties due to poor cellular yield and cell disruption, and a non-
9
diagnostic rate of 14% in cats has been reported. Therefore, a non-diagnostic sample or a finding of reactive should
not be held as definitively ruling out neoplasia.
Urinary Tract
Normal kidneys are 30-45mm in length. Fat deposited in the renal tubules in cats leads to a more
hyperechoic cortex in some animals. Bilateral pelvic dilation is often due to obstruction in male cats. Uni- or bilateral
pelvic or ureteral dilation in cats often occurs due to inflammation secondary to ureterolithiasis. If ureterolithiasis is
suspected and ureteral dilation is noted in ultrasound, abdominal radiographs following an enema should be
performed to screen for uroliths which may be challenging to find sonographically but easy to see radiographically.
Any toxin that cat ingests can also affect the kidneys. Ethylene glycol and Easter Lily are two and the retroperitoneal
space may develop fluid secondary to acute renal injury. Ethylene glycol affected kidneys may become so
hyperechoic that shadowing will result. Polycystic kidney disease in cats and results in several cysts in both kidneys
to complete absence of recognizable renal tissue. The cysts are thin walled, with a near and far wall hyperechoic
border and anechoic content.
Congenital defects of the kidneys include hypo- and dysplasia as well as aplasia. When young cats have
small and irregularly shaped kidneys, dysplasia is more likely than chronic renal disease. Chronic renal injury in cats
is due to chronic nephritis, glomerulonephritis, amyloidosis and nephrocalcinosis. In all cases the kidneys are smaller
in length, hyperechoic and often irregularly shaped. Loss of corticomedullary distinction is also apparent. Occasional
small round anechoic cortical cysts are identified as well. Chronic renal injury can also lead to uremic gastropathy
which sonographically appears as hyperechoic mucosal borders. Cryptococcus and feline infectious peritonitis can
both lead to chronic renal injury and the sonographic findings are variable.
Renal infarcts can be commonly identified and are typically incidental findings, especially in older cats. They
are wedge shaped hyperechoic non-shadowing cortical lesions, located anywhere in the kidney.
Renal neoplasia in the cat is often due to lymphoma which can appear a nodules or diffuse cortical echogenicity and
enlargement. Specific to cats is a hypoechoic halo around the kidney that can be present with lymphoma, but also
with renal infection such as with FIP.
Pseudocysts are not uncommon, especially in older cats. They are large, thin walled, anechoic fluid-filled
structures surrounding usually both kidneys. A urinoma secondary to renal or ureteral trauma can appear similarly
but is usually unilateral.
Track B
Suspended echoes that do not cause acoustic shadowing, reverberation, or twinkle artifact distal to the echo
may be due to urine lipid. Clumping of these echoes may be present. Hyperbilirubinemic animals can have similar
findings as can those with hematuria. Cystic calculi are hyperechoic and dependent and shadowing, not suspended.
Cats may have accumulations of fine crystals that collect and shadow but when agitated break apart and look like a
snow globe. Chronic cystitis can affect the cranioventral wall which becomes focally thickened with an irregular
mucosa. Cats will develop a hyperechoic and sometimes shadowing border facing the lumen due to mucosal
necrosis gas bubble entrapment, much like an ulcer. Pedunculated and broad-based masses can develop and can
be benign polyps as well as malignant neoplasms. Cats with hyperechoic renal cortices consistent with fat
10
deposition may have more echoes in the urinary bladder, presumably due to increased lipid shedding.
Pancreas
Chronic pancreatitis is poorly described in cats. The pancreas may be of normal size or enlarged with a
heterogenous appearance. Hyperechoic foci with acoustic shadowing may represent mineralizations. Multiple
hypoechoic round foci of a few millimeters in diameter may also be recognized. These may represent nodular
11
hyperplasia or dilated pancreatic ducts. Cavities of the pancreas cats are typically either due to abscesses or
12
pseudocysts and appear as anechoic or hypoechoic cavities, possibly with a thickened wall. A number of
investigators have attempted to assess the sensitivity and specificity of ultrasound compared to other imaging
13-15
modalities for diagnosing pancreatitis in cats, however, with greatly varying results. Ultrasound will most likely
remain one of the most important diagnostic tools in both dogs and cats as it allows not only assessment of the
pancreas, but also that of other organs that may be involved in the inflammatory process.
Identifying important landmarks is critical to localizing the pancreatic limbs as the pancreatic parenchyma
can be difficult to differentiate initially from the surrounding mesentery. It may have indistinct margins and be
isoechoic with the mesentery in the normal situation. The left lobe of the pancreas and body are easier to see than
105
the right. Pancreatic ducts are easy to see in most cats. Also, the major duodenal papilla is the common entrance of
the pancreatic and common bile duct in cats. The main landmark for identifying the left lobe and body in the cat is the
portal vein. The pancreatic body lies directly ventral to the portal vein caudal to the stomach. The left lobe is caudal
to the stomach and cranial to the transverse colon on the left side of the portal vein. It may continue caudally for a
small distance to the level of the splenic hilus. The pancreatic duct is more commonly identified in cats and is seen
as a small anechoic tubular structure in the body and left pancreatic lobe. The right lobe of the pancreas is small in
the cat and is more difficult to identify. It is adjacent to the duodenum and follows it caudally. A small pancreatic duct
can also be identified in it. The major duodenal papilla appears as a small nodule attached to the duodenal wall close
to the cranial flexure.
The following are parameters that should be assessed when examining the feline pancreas:
Size
The left and right limbs as well as the body should be examined and measured for thickness in the sagittal
plane. Normal: Body: 0.5-0.9cm thick, Left lobe: 0.4=10cm thick, right lobe: 0.3-0.6cm.
Abnormal: In acute disease, the pancreas may become enlarged as in dogs. However, this finding is much
more inconsistent in cats. In chronic disease the pancreas may be of normal size or smaller. Unremarkable changes
do not rule out pancreatitis in cats. Pancreatic size does not increase with increasing age.
Echogenicity
Normal: iso- to hypoechoic with the mesentery. Abnormal: The pancreas usually becomes hypoechoic in
acute disease. In chronic disease the pancreas may have a normal, hypo or hyperechoic appearance. Pancreatic
echogenicity does not change with increasing age.
Echotexture
Normal: finely textured. Abnormal: Often the pancreas appears heterogeneous. It can become nodular with
irregular borders. Nodular hyperplasia has the appearance of small hypoechoic distinct nodules throughout the
parenchyma. It is commonly seen in older cats. Nodules may be up to 1cm in diameter and the pancreas may be
enlarged.
Pancreatic duct size: Normal:0.5-2.5mm diameter. Too little is known about the size of the duct in disease.
16
However, there is a slight increase in size of the duct in older cats.
Adrenal Glands
Normal feline adrenal glands are 1cm in length, 3.7-4.9mm pole height, have an ovoid shape and are
17
hypoechoic. Cats with hyperthyroidism may have 20% larger glands, which can be explained by the stimulation of
the hypothalamic-pituitary-adrenocortical axis by hyperthyroidism. Treated hyperthyroid cats had a length of 1.1cm
and up to a 4.9mm pole height. Untreated hyperthyroid cats can have a gland length of 1.5 cm and pole height of up
to 4.9mm. This study showed that these measurements were significantly greater than in control cats. Hyperthyroid
cats also had more hyperechoic parenchymal foci than controls and were thought to be due to fat deposition,
Track B
hemorrhage or small calcifications. No shadowing was present. Adrenal tumors most always lead to much greater
size changes, rather in the centimeter rather than mm range. Adrenal tumors in cats with hyperaldosteronism are
typically 2-4cm in size. Cats with acromegaly can have bilateral enlargement also.
References
1. Nyland TG, Koblik PD, Tellyer SE: Ultrasonographic evaluation of biliary cystadenomas in cats. Veterinary
radiology & ultrasound : the official journal of the American College of Veterinary Radiology and the
International Veterinary Radiology Association 1999, 40:300-6.
2. Hittmair KM, Vielgrader HD, Loupal G: Ultrasonographic evaluation of gallbladder wall thickness in cats.
Veterinary radiology & ultrasound : the official journal of the American College of Veterinary Radiology and
the International Veterinary Radiology Association 2001, 42:149-55.
3. Gaillot HA, Penninck DG, Webster CR, Crawford S: Ultrasonographic features of extrahepatic biliary
obstruction in 30 cats. Veterinary radiology & ultrasound : the official journal of the American College of
4. Atiee G, Kvitko-White H, Spaulding K, Johnson M: Ultrasonographic appearance of histoplasmosis identified
in the spleen in 15 cats. Veterinary radiology & ultrasound : the official journal of the American College of
5. Couturier L, Rault D, Gatel L, Belli P: Ultrasonographic characterization of the feline cardia and pylorus in 34
healthy cats and three abnormal cats. Veterinary radiology & ultrasound : the official journal of the American
College of Veterinary Radiology and the International Veterinary Radiology Association 2012, 53:342-7.
6. Marolf AJ, Bachand AM, Sharber J, Twedt DC: Comparison of endoscopy and sonography findings in dogs
and cats with histologically confirmed gastric neoplasia. The Journal of small animal practice 2015, 56:339-
44.
106
7. Zwingenberger AL, Marks SL, Baker TW, Moore PF: Ultrasonographic evaluation of the muscularis propria in
cats with diffuse small intestinal lymphoma or inflammatory bowel disease. Journal of veterinary internal
medicine / American College of Veterinary Internal Medicine 2010, 24:289-92.
8. Taeymans O, Holt N, Penninck DG, Webster CR: Ultrasonographic characterization of feline ileocecocolic
abnormalities. Veterinary radiology & ultrasound : the official journal of the American College of Veterinary
Radiology and the International Veterinary Radiology Association 2011, 52:335-9.
9. Amores-Fuster I, Cripps P, Graham P, Marrington AM, Blackwood L: The diagnostic utility of lymph node
cytology samples in dogs and cats. The Journal of small animal practice 2015, 56:125-9.
10. Sislak MD, Spaulding KA, Zoran DL, Bauer JE, Thompson JA: Ultrasonographic characteristics of lipiduria in
clinically normal cats. Veterinary radiology & ultrasound : the official journal of the American College of
11. Wall M, Biller DS, Schoning P, Olsen D, Moore LE: Pancreatitis in a cat demonstrating pancreatic duct
dilatation ultrasonographically. Journal of the American Animal Hospital Association 2001, 37:49-53.
12. Hines BL, Salisbury SK, Jakovljevic S, DeNicola DB: Pancreatic pseudocyst associated with chronic-active
necrotizing pancreatitis in a cat. Journal of the American Animal Hospital Association 1996, 32:147-52.
13. Saunders HM, VanWinkle TJ, Drobatz K, Kimmel SE, Washabau RJ: Ultrasonographic findings in cats with
clinical, gross pathologic, and histologic evidence of acute pancreatic necrosis: 20 cases (1994-2001).
Journal of the American Veterinary Medical Association 2002, 221:1724-30.
14. Gerhardt A, Steiner JM, Williams DA, Kramer S, Fuchs C, Janthur M, Hewicker-Trautwein M, Nolte I:
Comparison of the sensitivity of different diagnostic tests for pancreatitis in cats. Journal of veterinary internal
medicine / American College of Veterinary Internal Medicine 2001, 15:329-33.
15. Forman MA, Marks SL, De Cock HE, Hergesell EJ, Wisner ER, Baker TW, Kass PH, Steiner JM, Williams
DA: Evaluation of serum feline pancreatic lipase immunoreactivity and helical computed tomography versus
conventional testing for the diagnosis of feline pancreatitis. Journal of veterinary internal medicine / American
College of Veterinary Internal Medicine 2004, 18:807-15.
16. Larson MM, Panciera DL, Ward DL, Steiner JM, Williams DA: Age-relatedchanges in the ultrasound
appearance of the normal feline pancreas. Veterinary radiology & ultrasound : the official journal of the
American College of Veterinary Radiology and the International Veterinary Radiology Association 2005,
46:238-42.
17. Combes A, Vandermeulen E, Duchateau L, Peremans K, Daminet S, Saunders J: Ultrasonographic
measurements of adrenal glands in cats with hyperthyroidism. Veterinary radiology & ultrasound : the official
journal of the American College of Veterinary Radiology and the International Veterinary Radiology
NOTES:
Track B
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NOTES:
Track B
108
Lunch & Learn
Updates in Pain Management

Michael Petty, DVM, CVPP, CVA, CCRT, DAAPM
Introduction
Although there has been a dearth of new pharmaceuticals for the treatment of pain in cats, there is a
substantial amount of new information on how many of these pharmaceuticals can be used. Even more important
are the ancillary treatments that can be used to either compliment drug treatments or used alone to decrease pain
and increase quality of life.
Presentation of Pain
Behavioral changes are the number one consideration when assessing the presence of pain in cats.
Compared to many other species, cats are less likely to exhibit outward signs of pain, especially cats that are
suffering from chronic pain. Instead, they display behavior that pain-free cats do not. Below is a brief review of some
of the common behavioral changes seen in cats living with chronic pain.
Mobility Issues
Cats will limp in the case of acute injury to a limb. However with chronic issues such as degenerative joint
disease, limping is rarely seen.
Jumping problems can be seen either when the cat in pain is jumping up or jumping down from a height,
such as furniture. Cats may completely stop jumping up onto their favorite perches; a windowsill or other favorite
spot might become too high to reach. Some cats will still get to their favorite spots, but now must rely on taking
several smaller jumps, for example from a chair to a table or counter. The same can be true when jumping down
from a height; you might notice hesitation or a lack of grace when jumping.
The ability to climb or descend stairs might become impaired. The caregiver might see this as a disinterest
in sleeping with them in their bedroom, when the real problem is that it is just too painful to make it up the stairs.
Another common complaint by the caregeiver is inappropriate elimination. They should be questioned as to the
location and accessibility of the litter box; if it requires their cat to use stairs in order to reach it, she might not be able
to or feel it is worth the pain to reach it.
Grooming Issues
Cats may present to you with either matted fur or hygiene issues. Some cats find it too painful to make the
necessary contortions to properly groom their fur or their perineal area. Other cats develop a sudden dislike of being
brushed because their joints are painful. Matted fur and perineal infections can result and should be a signal to look
for an underlying cause such as DJD. Be aware that some of these cats come in with their fur shaved and although
some clients routinely have their cats fur cut short, they should be asked if it was done because of the presence of
mats or because their cat no longer wished to be brushed.
Elimination issues
Mobility problems were already discussed as one possible reason why cats suddenly stop using the litter box
when the box is too remote. Also consider DJD when cats eliminate next to the litter box. They may find it difficult to
get into the box, and go right next to it. Some cats will climb into the litter box but are unable to crouch, so use the
edge of the box for balance and eliminate outside of it even though they actually standing in the litter. And finally, if
the litter is too deep, it can become too hard to walk through.
Play and Socialization issues

Whether it is with other pets or their toys, painful cats become reluctant to either respond to attempts to play
and/or stop initiating play on their own. This can extend to interactions with their caregiver as well; self-imposed
Lunch & Learn
isolation by an increase in the amount of sleep, or reluctance to be held or touched because of the pain associated
with it.
Treatment Considerations
Pharmaceutical Treatments
There have been no new drugs for the treatment of chronic pain. Simbadol is the only new drug for the
treatment of acute pain. Although we do not have any new chronic pain drugs, there is an increased understanding of
how many of the existing pain drugs can be used. Time does not permit me to discuss the side effects and adverse
events of these medications, so you should familiarize yourself with these drugs prior to using them.
109
Tramadol has recently fallen out of favor for its use in dogs. It has been discovered in that species that they
do not make any significant amounts of the opioid metabolite. This is not true in cats and can certainly be considered
i
for treating both acute and chronic sources of pain. The problem that remains is administration because its
extremely bitter taste is all but impossible to hide, making it all but impossible to ever give a second dose of tramadol.
However, if you find a compounding pharmacy that can mask the bitter taste and you would like to use it, the dose is
1-2 mg/kg q12-24 hours. Unfortunately there are no available safety studies for the use of tramadol in cats.
Amantadine, a flu medication, has been shown to reduce signs of hyperalgesia and allodynia in cats. There
ii
is at least one pharmacokinetic study that has been done in cats. The dose for amantadine in cats is 3 mg/kg q24h.
Gabapentin is an anticonvulsant drug that has been found to down-regulate the calcium channels
responsible for the transmission of pain. There are at least two studies that demonstrate the benefit of gabapentin in
iii iv
DJD and musculoskeletal pain. The dose I have found most beneficial ranges from 12.5 to 50 mg q8h. I almost
always start with the lower dose, especially in aged cats, and work my way up if necessary.
Adequan is licensed only for use in dogs. However there have been studies showing the benefit of using it in
v
cats for the treatment of DJD. I recommend a dose of 5 mg/kg given subcutaneously twice weekly for one month,
then once monthly for maintenance.
NSAIDs are not licensed in the US for long-term use in cats. One NSAID available for single use in the U.S.,
meloxicam, also has a chronic indication in countries outside of the U.S. In addition, there has been a substantial
amount of post-labeling research that has shown the safety and efficacy of chronic administration of meloxicam in
vi vii viii
cats, even those cats with chronic renal disease. There are several recommended doses, but I typically use
0.025 to 0.05 mg/kg q24h.
Lidocaine was long thought to be dangerous when used intravenously in cats, as part of a constant infusion
of pain medications. It appears that this concern was overestimated and there are clinical reports of the successful
use of lidocaine as part of a CRI.
Maripotant, sold as Cerenia by Zoetis, has recently become popular after two studies that showed it had a
ix
pain-sparing effect similar to morphine in two separate dog studies. To date, there have not been any feline studies
performed. It is my clinical impression that cats receiving maripotant seem more comfortable post-surgically,
however this might be due to its anti-emetic effect. One survey among human patients revealed that post-surgical
nausea was worse than the post-surgical pain. This might be true with our feline patients as well.
Simbadol
Simbadol is the only new pharmaceutical for use in cats. It is buprenorphine, but unlike other forms of
buprenorphine, Simbadol can and should be given subcutaneously. Other forms of buprenorphine take about 20
minutes to full effect, however Simbadol takes one full hour. It may be used once daily for a total of three days.
Because its duration is 24 hours, this makes it a very convenient anesthetic premedication, allowing more
leeway for the start of painful procedures after it is given. In my practice, we give all cats that are in for surgery or
other painful procedures an injection of Simbadol upon admission. Cats that are presented because of an acute
painful condition are also given Simbadol upon admission.
Simbadol can be used in combination with other drugs, just as you would any opioid in cats. This includes
using it in many of the “kitty magic” combinations that include dexmedetomidine/medetomidine with or without
ketamine. Just remember to give it a full hour prior to administering the other drugs.
Simbadol use in my practice; a few examples.

1. Healthy young adult cat spay: Inject Simbadol 1 hour or more prior to surgery. Induction by preferred route
(alfaxalone, etc.) with inhalant for maintenance. Line block of incision. Meloxicam for recovery and to send
home.
2. Dental Extraction. Inject Simbadol 1 hour or more prior to surgery. Injection of ketamine and
dexmedetomidine. Dental block. Meloxicam for recovery and to send home.
Future Pain Treatments

There are several products in development for the treatment of pain. Some of these are being looked at for
cats and some for dogs but with the potential for use in cats.
Lunch & Learn
Grapiprant is one exciting product on the horizon, and it belongs to the piprant class of drugs. Grapiprant is
being developed by Aratana Therapeutics. This class of drugs targets the EP4 receptor in the COX pathway, but is
x
not considered an NSAID . This drug holds promise for the treatment of chronic pain without the adverse events
associated with NSAIDs.
NV-02 is a cat specific anti-NGF (Nerve Growth Factor) monoclonal antibody, which is being developed by
xi
Nexvet to control the pain of degenerative joint disease. NGF is responsible for mediating some of the pain signals
in cats with DJD. Patients would come in for periodic subcutaneous injections at the veterinary clinic in order to
control the pain of DJD.
110
Expercel is another Aratana Therapeutics product that utilizes bupivacaine that has been micro-
xii
encapsulated to deliver long-lasting pain relief after surgery. Bupivacaine normally lasts in the 5-6 hour range when
used to block a surgery site. Expercel has demonstrated up to 72 hours of pain relief post-operatively.
xiii
CNTX-4975 is a product that utilizes capsaicin to control the pain of DJD . Clinical trials by the company
Centrexion have so far been focused on knee OA in dogs, but capsaicin has been shown to effectively control pain in
many species, including cats. Capsaicin is what makes chili peppers hot, and its mode of action is to burn back the
nerve endings of C-fibers, which are responsible for the transmission of chronic pain signals.
xiv
XT-101 is a product being developed by Xalud! Therapeutics . XT-101 action is to mimic Interleukin-10 (IL-
10), a natural and potent anti-inflammatory. It has primarily been used in rodent and dog models, but has the
potential for cross-species use, including humans. It can be injected intrathecally to treat neuropathic pain or in the
joint to treat DJD.
Zydax is a patented sulfate ester made by the company Parnell. To date, it has only been looked at in the
treatment of OA in dogs and horses. There have been some claims made that it treats both the inflammation of OA
along with stimulating the growth of cartilage while managing some of the catabolic breakdown of cartilage.
Non-pharmaceutical Pain Interventions

xv
Acupuncture has been proven to be a benefit to treating cats in pain , especially those cats suffering from
chronic pain issues such as DJD. Most cats tolerate acupuncture when administered in a calm and quiet
environment while using gentle handling techniques. Acupuncture treatments include, but are not limited to:
• Osteoarthritis of all joints but especially hips, knees, elbows and spine
• Back pain secondary to IVDD
• Oro-fascial pain including dental disease
• Treatment of acute/post-surgical pain
Physical Rehabilitation has received recognition in its importance to treat pain in dogs over the past 15
years. More recently, its importance in treating acute and chronic pain conditions in cats is being recognized and
acted upon. Treatments include, but are not limited to:
• Recovery from acute injuries such as fractures
• Recovery from surgical procedures
• Osteoarthritis
• Back pain and injury, including paresis and paralysis
xvi
Myofascial Pain Syndrome has been recognized as a source of pain in humans for hundreds of years. In
more recent years its presence has been detected in most animal species, and its importance as a comorbidity of
many acute and chronic pain syndromes in cats has also been noted.
Nutritional Management has received increased attention as several recent studies have shown both the
benefit of a lean body mass and the effect of therapeutic diets on osteoarthritis.
Environmental Modifications, although not new, have seen an improvement with the ready availability of
products designed to help cats that have arthritis or are convalescing from an acute painful injury or procedure.
Orthopedic beds, ramps elevated food bowls, and steps are just a few of the products available.
Hospice Care is meant to treat pain in cats without treating the disease. There are times when the decision
to euthanize is not paramount for the caregiver, yet they wish to allow their cat’s final days, weeks or months to be as
xvii
pain free as possible. Hospice care is one way to let this happen. The fairly recent formation of the International
xviii
Association of Animal Hospice and Palliative Care can help provide support for the hospice veterinarian.
Pain Assessment Scales

There have been several quality of life and pain assessment scales developed in recent years. Most of
these have not been validated but the effort to do so has taken on a new importance. Using these scales, even
when not validated, provide the opportunity to have a conversation with the owner and to reassess those conditions
causing pain. These include:
xix
• Cancer pain
Lunch & Learn
xx xxi xxii
• Degenerative joint disease
xxiii xxiv
• Acute Pain
References
i
1. Brondani Ji, Loureiro Luna SP, Beier SL, et al. Analgesic efficacy of perioperative use of vedaprofen,
tramadol or their combination in cats undergoing ovariohysterectomy. J Feline Med Surg 2009; 11: 420–429.
ii
2. Siao KT, Pypendop BH, Stanley SD, et al. Pharmacokinetics of amantadine in cats. J Vet Pharmacol Ther
2011; 34: 599–604.
111
iii
3. Lorenz ND, Comerford EJ et al. Long-term use of gabapentin for musculoskeletal disease and trauma in
three cats. J Feline Med Surg 2013; 15: 507–512.
iv
4. Reid P, Pypendop BH and ilkiw JE. The effects of intravenous gabapentin administration on the minimum
alveolar concentration of isoflurane in cats. Anesth Analg 2010; 111: 633–637.
v
5. Heidrich JE, Fox SM, Royer R, et al. Fluorescein-labeled poly - sulfated glycosaminoglycan in a feline acute
traumatic knee model. Proceedings of the 35th Annual Conference of the Veterinary orthopedic Society;
2008 March 8–15; Big Sky, MT.
vi
6. Goodman LA, Brown SA, Torres BT, et al. Effects of meloxicam on plasma iohexol clearance as a marker
of glomerular filtration rate in conscious healthy cats. Am J Vet Res 2009; 70: 826–830.
vii
7. Lascelles BDX, Henderson AJ, Hackett iJ, et al. Evaluation of the clinical efficacy of meloxicam in cats with
painful locomotor disorders. J Small Anim Pract 2001; 42: 587–593.
viii
8. Gowan RA, Lingard AE, Johnston L, et al. Retrospective casecontrol study of the effects of long term
dosing with meloxicam on renal function in aged cats with degenerative joint disease. J Feline Med Surg
2011; 13: 752–761.
ix
9. Giordano T, Steagall PV, Ferreira TH, et al. Postoperative analgesic effects of intravenous, intramuscular,
subcutaneous or oral transmucosal buprenorphine administered to cats under -going ovariohysterectomy.
Vet Anaesth Analg 2010; 37: 357–366.
x
10. http://aratana.com/for-veterinarians/pain
xi
11. nexvet.com/therapies/nv-02/
xii
12. aratana.com/therapeutics/pipeline/pain
xiii
13. https://www.agra-net.net/agra/animal-pharm/interviews/centrexion-to-use-capsaicin-for-animal-pain-relief-
358534.htm
xiv
14. xaludthera.com/products/
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15. Fry LM, Neary S, Sharrock J, et al. Acupuncture for analgesia in veterinary medicine. Top Comp Anim Med
2014; 29: 35–42.
xvi
16. Dommerholt J and Huijbregts P. Myofascial trigger points: pathophysiology and evidence-informed
diagnosis and management. Sudberry, MA; Jones and Bartlett, 2011.
xvii
17. Shanan A. A veterinarian’s role in helping pet owners with decisionmaking. Vet Clin North Am Small Anim
Pract 2011; 41: 635–46
xviii
18. https://www.iaahpc.org/
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19. Lynch, S et al. Vet Comp Oncol Development of a questionnaire assessing health-related quality-of-life in
dogs and cats with cancer 2011 Sep;9(3):172-82
xx
20. Zamprogno, H et al. Am J Vet Res Item generation and design testing of a questionnaire to assess
degenerative joint disease associated pain in cats 2010 Dec;71(12):1417-24
xxi
21. Benito, J J Vet Intern Med, Feline musculoskeletal pain index: responsiveness and testing of criterion
validity. 2013 May-Jun;27(3):474-82
xxii
22. Colorado State University Feline Acute Pain Scale (Available on the Internet)
xxiii
23. UNESP-Botucatu Multidimensional Composite Pain Scale for assessing
24. postoperative pain in cats. (Available on the Internet www.animalpain.com.br/en-us/avaliacao-da-dorem-
gatos.php)
xxiv
25. Colorado State University Feline Acute Pain Scale (Available on the Internet
csuanimalcancercenter.org/assets/files/csu_acute_pain_scale_feline.pdf)
NOTES:
Lunch & Learn
112
2015
3 WORLD FELINE
rd
VETERINARY
CONFERENCE SATURDAY, OCTOBER 3, 2015
TRACK A TRACK B PARA-PROFESSIONAL

Grand Hall C Grand Hall D Cortez Hill A
FUN RUN
Separate registration required 6:30 am

7:30 – 8:30 am
8:15 am – 12:15 pm Feline Dental Radiology Masterclass
Imaging of Round Cell MRI & CT for Feline Understanding the Cat &
Neoplasia in the Cat Practitioners Feline-friendly Handling: Part 1 8:30 – 9:20 am
Dr. Zoe Lenard Sponsored by Dr. Livia Benigni Dr. Ilona Rodan Sponsored by
CT of the Feline Choosing & Using Radiology Understanding the Cat

Head & Ultrasound Equipment & Feline-friendly Handling: Part 2 9:25 – 10:15 am
Dr. Zoe Lenard Dr. Livia Benigni Dr. Ilona Rodan
NETWORKING REFRESHMENT BREAK in Exhibit Hall

10:15 – 10:45 am
10:20 – 10:45 am AAFP Membership Meeting – Torrey Hills A
Managing the Feline Cancer Patient: Part 1 Kitties in Crisis: Emergency

Dr. Erika Krick Sponsored by Care for Cats Sponsored by 10:45 – 11:35 am
Ms. Erica Mattox
Managing the Feline Cancer Patient: Part 2 How to Survive the Hospitalized
Dr. Erika Krick Cat: Feline Patient Care 11:40 – 12:30 pm
Ms. Erica Mattox

Update on Feline Anaplasmosis, Dr. Michael Lappin – Hillcrest A

12:30 – 2:00 pm
1:20 – 1:50 pm ABVP: Is It For Me? – Grand Hall C
1:30 – 5:30 pm Feline Dental Radiology Masterclass
Oral Tumors in Cats: Hope Feline Lymphoma Kitties vs. Kidneys: Feline
for the Future Sponsored by
Dr. Erika Krick
Sponsored by
Kidney Disease Sponsored by 2:00 – 2:50 pm
Management of Feline Neoplastic Effusions Trouble in the Urethra: Feline

Large-cell Lymphoma Updates Dr. Erika Krick Lower Urinary Tract Disease 2:55 – 3:45 pm
FREE TIME
3:45 – 6:30 pm
3:50 – 4:45 pm Cat Friendly Practice Forum – Grand Hall D
Sponsored by
Polynesian Paradise Offsite Event 6:30 – 10:30 pm

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Managing the Feline Cancer Patient: Part 1 & 2

Erika Krick, VMD, DACVIM (Oncology)
Generalist
Combined
Introduction
Cancer treatment of both cats and dogs has been on the rise both in specialty and primary care practices. A
survey of veterinary practices in the UK showed that 70.8% of practices had used cytotoxic therapy in the past year,
1
and 39.6% had referred a patient to another practice for cytotoxic therapy. The median frequency of cytotoxic drug
prescriptions (oral or injectable) was every 3 months. Of the practices that prescribed cytotoxic drugs, the most
common drugs prescribed were cyclophosphamide (used by 92.4% of practices) and vincristine (89.6%), followed by
chlorambucil (42.8%) and doxorubicin (30.1%). Given the frequency of lymphoma in dogs and cats, it is not
surprising that these drugs are the most often prescribed. These data show that treatment of cancer in pets is quite
common in the UK, and it is reasonable to think that it is quite common in the US as well.
Compared to humans and other domestic animals, cats are a unique species in so many ways—they are
obligate carnivores, they are predators, their hepatic metabolism is quite different, many still bear a striking
resemblance to their larger, wilder cousins in both appearance and behavior, and for the most part their body size is
Para-professional
relatively uniform across breeds. Their cancers are unique as well. Unlike other species, multicentric lymphoma is
quite uncommon in cats, while the intestinal tract is the most common anatomic site. Several different types of
lymphoma have been characterized in the cat, with separate treatment recommendations and prognostic
expectations outlined. Their appendicular osteosarcoma is unlikely to metastasize, and mast cell tumor of their
spleen is quite treatable. In these sessions we will discuss the joys and challenges about treating cancer specifically
in cats.
Diagnosis
The process of diagnosing cancer in cats is similar to other species, and staging tests are similar as well.
Depending on the type of cancer a cat has and the clinical status of the patient, cytology or biopsy may be the
recommended procedure. Depending on the location of the organ or mass in question, there are several options for
2
obtaining these samples. Options include ultrasound-guided fine needle aspiration, ultrasound-guided Tru-cut
biopsy, endoscopy, laparoscopy, and open abdominal exploratory surgery. The recommended diagnostic test or
tests depend on the differential diagnoses, physical examination findings, results of diagnostic tests performed up to
that point, and the patient’s status.
Staging
As in other species, the recommended staging tests for cats with cancer depend on the diagnosis. For cats
who present for not feeling well and are ultimately diagnosed with cancer, many of the staging tests will have already
been performed as part of their diagnostic work-up and no additional staging tests may be necessary. Because the
vast majority of feline mammary tumors are malignant, it is recommend to perform staging (chest x-rays, lymph node
palpation and aspiration if palpable, and possible abdominal ultrasound) prior to removing the mass and having a
biopsy-confirmed diagnosis.
Treatment Challenges
Drug Delivery
The primary options that are available for treating cats with cancer are similar to those available for other
species. Cats, however, can present some unique challenges regarding drug administration. Some cats are
intolerant of laying still for an IV injection or infusion and may require sedation for safe administration of the
chemotherapy drugs that are tissue irritants or vesicants, such as the vinca alkaloids and doxorubicin. Sedation
adds time and cost to the visit, and sedating a patient weekly for treatments is not ideal. One possible solution is to
administer the drugs IP (intraperitoneally), which may be better tolerated and safer for the cat and the people
administering the chemotherapy. When the IP administration of vincristine and cyclophosphamide to 26 cats
receiving a COP-based protocol for lymphoma was retrospectively reported, no adverse effects related to the IP
Advanced
3
injections were noted. The response rate in the study was 76.9%, and the partial response rate was 19.2% (only one
cat did not respond to treatment), which is similar to or better than other reports of COP protocols for feline
lymphoma. The median disease free interval was 421 days, which again is similar or better to other reports. The
cats tolerated the IP injections well, and the authors comment that no cat handler was injured during the treatments.
Regarding the positive response to treatment, it is important to note that 10 of the cats had nasal lymphoma, which
could have skewed the results towards a more favorable outcome compared to other studies. However, the study
shows that IP chemotherapy administration appears to be well-tolerated and may be an effective substitute for
sedation and IV chemotherapy. The bioavailability of IP vincristine and cyclophosphamide in healthy cats is 100%
4
and 76%, so it seems like a reasonable method of drug delivery in this species.
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Some cats are extremely resistant to oral medications, and that can be a significant source of stress for
clients and can be damaging to the cat-owner bond. For cats who receive several medications, gelcaps can be very
helpful. If the individual mediations are small enough, the client can place them in a gelcap so that only 1 pill is
administered. Another option is to compound 2 drugs together, which some pharmacies offer. In the author’s
Generalist
practice we will offer weekly or every other week cyclophosphamide (50 mg per cat) to cats with small cell lymphoma
Combined
or multiple myeloma who will not tolerate the every other day dosing of their standard chemotherapy protocols
(chlorambucil and melphalan, respectively). The author does not recommend ordering chemotherapy drugs to be
compounded as a liquid, which increases the risk of exposure of other members in the household particularly if the
cat spits out the liquid or hypersalivates afterwards.
Transdermal formulations of prednisolone and supportive care medications can be attempted, but
pharmacological data regarding bioavailability of those drugs applied transdermally is unknown. Therefore, if the cat
does not respond to the medication, it could be because the medication is not working for the cat or that it is not
being absorbed. The author does not recommend administering chemotherapy drugs in this fashion as the risk for
exposure to the household is extremely high.
For the few cats and clients for whom subcutaneous injections are better tolerated (by the cat and the
owner!) than oral medications, that administration route can be used for glucocorticoids (dexamethasone) and some
supportive care medications (such as maropitant). Again, the author does not recommend allowing owners to
administer chemotherapy at home in this fashion. For example, if we have a patient who is due for cytarabine
Para-professional
treatment, we recommend admission to the hospital for a slow infusion of up to 24 hours long.
Yet another route of administration of medication in cats is oral transmucosal (OTM). This route has been
evaluated for buprenorphine in cats, and one study found that the pharmacokinetics and efficacy of OTM versus IV
5
administration was similar. A randomized controlled study evaluating the post-operative analgesic effect of
buprenorphine administered in 4 ways (IV, IM, SC, OTM) showed that pain control was significantly better with IV or
6
IM administration compared to SC and OTM routes. Cancer-related pain is likely different from post-operative pain,
so buprenorphine given OTM will likely be beneficial for most cats. This method of drug delivery does not require the
cat to actually swallow the medication once it is in his/her mouth which increases the ease of administration.
Supportive Care
Improving quality of life is a primary goal of treating cancer in cats, and it is of particular importance to
consider the quality of life in cats who are ill from their cancer at the time of diagnosis. It can be challenging to
improve their cancer-related clinical signs while balancing potential side effects from chemotherapy. Fortunately we
have a host of supportive care medications at our disposal, assuming that the client can get them into the cat! The
most common cancer clinical signs and chemotherapy side effects that affect quality of life in cats are
nausea/vomiting, decreased appetite, and weight loss. The authors most commonly uses ondansetron and
maropitant to treat nausea in cats with cancer, while maropitant and/or prednisolone can be used if potential nausea
has been treated but the cat’s appetite remains poor. Depending on the cat’s clinical status (end-stage palliative
care versus just beginning treatment), if the appetite does not improve with the drugs mentioned above, then
treatment with megestrol acetate may be reasonable. To reduce the risk of the cat experiencing complications from
that treatment, such as diabetes mellitus or mammary carcinoma development, it is wise to use that drug only in
7
carefully selected patients. Megestrol acetate is a potent suppressor of the hypothalamic-pituitary-adrenal axis, so it
is essential to inform clients not to stop that mediation abruptly. Changes in post-ACTH cortisol levels were seen as
8
quickly as 1 week after starting treatment in healthy cats given megestrol acetate. Different healthy cats in that study
received prednisolone, which did not suppress the axis to the same degree.
Assisted enteral feeding with feeding tubes is a controversial issue in feline oncology. The benefits of a
feeding tube are that the client is able to get an adequate amount of nutrition and water into the cat, and the number
of calories being consumed is easier to measure than with free feeding. Owners can often give many medications
via the feeding tube, which is often less stressful on the owner and the cat. The downside is that a feeding tube
gives a client a way to keep their cat alive in the face of extreme discomfort and thus prolong instead of minimize
suffering. For that reason it is important to communicate effectively with the client about the purpose of the feeding
tube and make sure that you understand the client’s goals and expectations for their cat’s clinical situation.
Two previous studies examining the outcome of feeding tube placement in cats found that most owners were
Advanced
9,10
comfortable with using their cat’s esophagostomy tube. One of these studies compared the placement and usage
9
of 21 percutaneous endoscopic gastrostomy (PEG) versus 46 esophagostomy (E) tubes in feline patients. Liver
disease (post commonly hepatic lipidosis) and cancer were the most common diseases of cats included in the study.
All of the owners of cats with PEG tubes surveyed (12 owners) stated that they were comfortable using the tube,
while all 96% of owners were comfortable with their cat’s E tube (one out of the 24 clients surveyed was not
comfortable using the tube). There were no significant differences between PEG and E tubes according to number
and severity of complications, owner comfort level, owner difficulty (or lack thereof) with initial feedings, and weight
change while the tube was in place. The number of days the tube was in place was significantly shorter for E tubes
versus PEG tubes. Another study specifically evaluated E tube placement in 60 cats and found that most patients
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either gained weight or had stable weight while being fed through the E tube, and the mean duration of the tube in
10
the cats was 23 days. Noted complications included vomiting (including vomiting the tube), swelling of the head,
and inflammation or infection at the tube site. Such complications occurred in about 1/3 of patients. It is worth noting
that both of these studies were published between 18 and 12 years ago, and it is reasonable to think that skill level
with tube placement, owner communication about using the tubes, and available diets for enteral tube feeding have
Generalist
improved in the past 2 decades. To the author’s knowledge, no more recent studies have been published showing
Combined
clinical effects on body weight of and owner satisfaction with E tubes in cats. For cats that have been inappetant or
anorexic due to their cancer, a feeding tube may help to improve their nutritional state while cancer treatment is
started. Not every patient will gain weight when adequate caloric consumption is achieved, however. Persistent
weight loss in the face of adequate caloric intake is a hallmark of cancer cachexia syndrome.
Cancer Cachexia
Cancer cachexia is well-described in human medicine, though it is such a complex and multi-factorial
syndrome that no standard of care treatment currently exists for it. Common aspects of cancer cachexia include
weight loss despite adequate caloric intake, loss of muscle mass, early satiety, decreased appetite, increased serum
11-16
levels of inflammatory cytokines, and poor tolerance of and response to cancer treatment. Cancer cachexia is
estimated to affect more than 1.3 million people and up to 80% of patients with some cancers, such as
17,18
gastrointestinal, colorectal, pancreatic, and lung cancers. Cancer cachexia itself is an independent prognostic
12,13
factor for survival in human cancer patients.
Para-professional
So what about cats? Certainly a fair number of our feline cancer patients struggle with weight loss and food
consumption. Owners also often note signs of early satiety—the cat goes to the food bowl and seems interested, but
stops eating after just a few bites. One could argue that the weight loss experienced by feline cancer patients is
simply due to inadequate caloric intake because they are feeling ill from their cancer, their cancer treatment, or both.
That scenario would not explain the specific muscle loss seen in many cats with cancer. In starvation (inadequate
caloric intake) the body works to conserve muscle so fat tissue is primarily lost. In cachexia the opposite occurs—the
body preferentially breaks down muscle so muscle mass is lost, with or without loss of fat mass.
The vast majority (91%) of cats with cancer exhibit clinically evident loss of muscle mass, while most (but not
as many-60%) of cats had clinically evident loss of adipose tissue in a prospective study examining the effect of body
19
weight and body condition score in cats with cancer. Both body weight and body condition score were significantly
inversely associated with survival (cats with lower body weight or body condition score had shorter survival). Both
were associated with remission status as well, as cats in remission from their cancer had significantly higher body
weights and body condition scores compared to cats that were not in remission. Other studies have demonstrated
that cats that have lost weight prior to starting chemotherapy or that weigh less than the median weight for cats in the
20,21
study at the beginning of chemotherapy have a shorter survival time.
A recent retrospective study compared survival of cats that were undergoing chemotherapy for lymphoma
22
according to how their weight changed during treatment. Cats with small cell and large cell lymphoma were
included in this retrospective study, and weight data from baseline and months 1, 2, 3, and were recorded and
compared. Cats were grouped as gained, lost, or stable weight based on whether their weight at the treatment time
points was at least 5% more, at least 5% less, or less than 5% changed compared to baseline. No differences in
survival were noted according to weight change for cats with small cell lymphoma. A difference was noted in cats
with large cell lymphoma 1 month into treatment. Specifically, cats that lost at least 5% of their body weight
compared to baseline had a significantly shorter survival compared to the other cats. The same trend was seen at
the 2 month time point but no statistical significance was achieved. Interestingly 21 of the cats in that study had
enteral feeding tubes. The tubes were more likely to be placed in cats with small cell lymphoma, and enteral feeding
tube placement was not significantly associated with weight change.
The information from these studies confirms that baseline body weight and changes in body weight during
treatment are prognostic for survival in cats with cancer, specifically lymphoma. When added to the finding that the
majority of cats with cancer have clinically evident loss of muscle mass, one can make the argument that some cats
with cancer exhibit clinical aspects of cancer cachexia. The unanswered question is what metabolic abnormalities
occur in cats that have clinical cancer cachexia and if these abnormalities are similar to human patients.
Increased alpha1-acid glycoprotein has been documented in cats with cancer, and specifically cats with
23,24
lymphoma, compared to healthy cats. In cats with lymphoma, the level of alpha1-acid glycoprotein did not
Advanced
correlate with survival or remission status. Neither study grouped cats according to weight, body condition score, or
muscle mass.
The author is currently enrolling cats in a study to compare serum levels of several inflammatory cytokines
(including feline specific acute phase proteins alpha 1-acid glycoprotein and serum amyloid A) among cachectic cats
25
with cancer, non-cachectic cats with cancer, and healthy cats. Cats with cancer with a body condition score of < 3
out of 9 and/or moderate to severe muscle wasting are classified as cachectic. Preliminary results from the first 27
cats enrolled showed that serum amyloid A was significantly higher in cachectic cats with cancer compared to
healthy cats. Serum alpha 1-acid glycoprotein was significantly higher in cachectic cats with cancer compared to
non-cachectic cats with cancer and in cachectic cats with cancer compared to healthy cats.
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Quality of Life
Only one study has specifically examined clients’ perceptions of the quality of life of their cat during
26
chemotherapy. Overall, most clients (83%) were happy with their decision to treat their cat with chemotherapy, and
87% said that they would treat another cat. Owners also identified markers of quality of life in their cats. The most
Generalist
commonly cited indicator was appetite (mentioned by 92% of owners), followed by playing/having fun, being
Combined
interactive, general demeanor, and having energy. Owners were also asked about their cat’s quality of life at
different time points. Not surprisingly, mean quality of life scores were highest prior to cancer diagnosis and
chemotherapy, and they were higher after starting chemotherapy compared to before starting chemotherapy.
Owners of cats who were deceased at the time of the survey were significantly less likely to report being happy that
they treated their cats, and owners of cats who experience chemotherapy side effects were more likely to regret their
decision to treat their cat with chemotherapy. Owners in this study were surveyed just once about a variety of time
points, so there is a high risk of recall bias in this study. It would be interesting to survey owners in real time multiple
times during treatment of their cat for lymphoma to better determine how clients feel their cats are feeling during
treatment before they know the outcome of their cat’s disease. The selection of “appetite” as an indicator of quality
of life by almost all owners indicates that clients are likely as concerned with their cat’s appetite as we are by their
cat’s weight, and the two are certainly related.
Communication
Para-professional
Effective communication is essential to any veterinarian-client interaction. In the author’s opinion it is

especially important when treating feline patients because they often act very differently at home compared to at the
veterinarian’s office. It is therefore key to learn as much as possible from the client about the cat’s behavior at home
to get a sense of the level of the cat’s quality of life. For example, if a client says a cat is eating, but the cat is
persistently losing weight, it is helpful to find out what the cat’s feeding behavior is at home. The cat may actually be
consuming an adequate amount of food, or he/she could be going to the food bowl frequently but be consuming only
a very small amount. Making this distinction may change your diagnostic and/or treatment plan for the cat.
Medication adherence can be particularly challenging for cat owners. If the cat resists being medicated, then
that struggle can really impact the bond between the owner and the cat. If not specifically asked about it in an
empathetic and non-judgmental way, some owners may not tell the veterinarian how badly things are going with
medications or that they are unable (or unwilling) to administer some medications. That information would likely
affect treatment recommendations going forward and would open the door to discussing any alternatives to the cat’s
current medications and formulations. Prior studies that have surveyed clients regarding their expectations for
communication from veterinarians show that clients expect to receive the truth (accurate information about what is
27,28,29
going on with their pet) in an empathetic, compassionate, non-rushed, non-judgmental way. Similarly, another
study found that clients were significantly more likely to adhere to surgical and dental care recommendations when
30
the veterinarian’s recommendations were clear. Given these results it is important not only to give clients clear
options and recommendations but to deliver that information in a way that promotes client understanding and
27,29
retention. For example, giving information in multiple forms (written, oral, charts/pictures) is preferred by clients.
Pausing often to minimize “information overload”, and asking for the client’s feedback about your recommendations
and the information you have shared gives you and the opportunity to check in to see if what you are saying is being
heard and understood. Two of the above studies included only dog owners, but it is likely that the preferences are
27,28
translatable to cat owners.
From the information above the author also suggests that we keep clarity and compassion as primary goals
in communicating with clients—clarity regarding what we say and what we understand from what the client says.
Treating cancer in a cat can be a roller coaster ride with many up days and down days, and it is important to start
building trust from the beginning to ensure quality patient care, client care, and veterinarian self-care.
References
1. Cave TA, Norman P, Mellor D. Cytotoxic drug use in treatment of dogs and cats with cancer by UK
veterinary practices (2003-2004). J Sm Anim Prac 48:371, 2007.
2. Louwerens M, London CA, Pederson NC, et al: Feline lymphoma in the post-feline leukemia virus era. J Vet
Intern Med 19:329, 2005
Advanced
3. Teske E, van Lankveld AJ, Rutteman GR. Intraperitonal antineoplastic drug delivery: experience wth a
cyclophosphamide, vincristine, and prednisolone protocol in cats with malignant lymphoma. Vet Comp Onc
12:37-46, 2012.
4. Voorhorst MJ, van Maarseveen EM, van Lankveld AJ, et al: Bioavailability of cyclophosphamide and
vincristine after intraperitoneal administration in cats. Anticancer Drugs 25:1211, 2014.
5. Robertson SA, Lascelles BD, Taylor PM, et al: PK-PD modeling of buprenorphine in cats: intravenous and
oral transmucosal administration. J Vet Pharmacol Ther 28:453, 2005.
6. Giordano T, Steagall PV, Ferreira TH, et al: Postoperative analgesic effects of intravenous, intramuscular,
subcutaneous, or oral transmucosal buprenorphine administered to cats undergoing ovariohysterectomy.
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Vet Anaesth Analg 37:357, 2010.
7. Mauldin, GE: Nutritional management of the cancer patient. In Withrow SJ and Vail DM, editors: Withrow and
MacEwen’s Small Animal Clinical Oncology, ed 4, Saunders Elsevier, 2007, p 307.
8. Middleton DJ, Watson AD, Howe CJ, et al: Suppression of cortisol responses to exogenous
adrenocorticotrophic hormone, and the occurrence of side effects attributable to glucocorticoid excess, in
Generalist
cats during therapy with megestrol acetate and prednisolone, Can J Vet Res 51:60, 1987.
Combined
9. Ireland LM, Hohenhaus AE, Broussard JD, et al: A comparison of owner management and complications in
67 cats with esophagostomy and percutaneous endoscopic gastrostomy feeding tubes: J Am Anim Hosp
Assoc 39:241, 2003.
10. Levine PB, Smallwood LJ, Buback JL: Esophagostomy tubes as a method of nutritional management in cats:
a retrospective study. J Am Anim Hosp Assoc 33:405, 1997.
11. Fearon K, Strasser F, Anker SD, et al: Definition and classification of cancer cachexia: an international
consensus. Lancet Oncol 12:489, 2011.
12. Fearon KC, Voss AC, Hustead DS, et al. Definition of cancer cachexia: effect of weight loss, reduced food
intake, and systemic inflammation on functional status and prognosis. Am J Clin Nutr 83:1345, 2006.
13. Dewys WE, Begg C, Lavin PT, et al: Prognostic effect of weight loss prior to chemotherapy in cancer
patients. Eastern Cooperative Oncology Group. Am J Med 1980;69:491-497.
14. Tisdale MJ: Biology of cachexia. JNCI 89:1763, 1997.
15. Stephens NA, Skipworth RJ, Fearon KC: Cachexia, survival, and the acute phase response. Curr Opin
Para-professional
Support Palliat Care 2:267, 2008.
16. Krzystek-Korpacka M, Matusiewicz M, Diakowska D, et al: Impact of weight loss on circulating IL-1, IL-6, IL-
8, TNF-alpha, VEGF-A, VEGF-C and midkine in gastroesophageal cancer patients. Clin Biochem 40:1353,
2007.
17. Morley JE, Thomas DR, Wilson MM: Cachexia: pathophysiology and clinical relevance. Am J Clin Nutr
83:735, 2006.
18. Von Haehling S, Anker SD: Cacheia as a major underestimated and unmet medical need: facts and
numbers. J Cachexia Sarcopenia Muscle 1:1, 2010.
19. Baez JL, Michel KE, Sorenmo K, et al.: A prospective investigation of the prevalence and prognostic
20. significance of weight loss and changes in body condition in feline cancer patients, J Feline Med Surg 9:411,
21. 2007.
22. Hadden AG, Cotter SM, Rand W, et al: Efficacy and toxicosis of VELCALP-C treatment of lymphoma in cats.
23. J Vet Intern Med 22:153, 2008.
24. Krick EL, Cohen RC, Gregor TP, Sorenmo KU. Prospective clinical trial to compare vincristine and
vinblastine
25. in a COP-based protocol for lymphoma in cats. J Vet Intern Med 27:134, 2013.
26. Krick EL, Moore RH, Cohen RB, et al.: Prognostic significance of weight changes during treatment of feline
27. lymphoma, J Feline Med Surg 13:976, 2011.
28. Selting KA, Ogilvie GK, Lana SE, et al: Serum alpha 1-acid glycoprotein concentrations in healthy and tumor-
bearing cats. J Vet Intern Med 14:503, 2000.
29. Correa SS, Mauldin GN, Mauldin GE, et al: Serum alpha 1-acid glycoprotein concentration in cats with
lymphoma. J Am Anim Hosp Assoc 37:153, 2001.
30. Krick E, Bence K, Michel K. Cachexia and inflammatory cytokines in cats with cancer. Proceedings of the
Veterinary Cancer Society Meeting, 2012.
31. Tzannes S, Hammond MF, Murphy S, et al: Owners’ perception of their cats’ quality of life during COP
chemotherapy for lymphoma. J Feline Med Surg 10:73, 2008.
32. Stoewen DL, Coe JB, MacMartin C, et al: Qualitative study of the communicatio expecations of clients
accessing oncology care at a tertiary referral center for dogs with life-limiting cancer. J Am Vet Med Assoc
245:785, 2014.
33. Stoewen DL, Coe JB, MacMartin C, et al: Qualitative study of the information expectations of clients
accessing onoclogy care at a tertiary referral center for dogs with life-limiting cancer. J Am Vet Med Assoc
245:773, 2014.
34. Coe JB, Adams CL, Bonnett BN: A focus group study of veterinarians’ and pet-owners’ perceptions of
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veterinarian-client communication in companion animal practice. J Am Vet Med Assoc 233:1072, 2008.
35. Kanji N, Coe JB, Adams CL, et al: Effect of veterinarian-client-patient interactions on client adherence to
dentistry and surgery recommendations in companion-animal practice. J Am Vet Med Assoc 240:427, 2012.
NOTES:
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Advanced Para-professional Combined
Generalist
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Imaging of Round Cell Neoplasia in the Cat

Generalist
Introduction
Lymphoma is the most common round cell neoplasia in the cat and shows great diversity of morphology and
biological behavior. Lymphoma can be classified based on its anatomical location and its cytomorphological grade,
1
with high-grade lymphoma having reduced median survival times than low grade forms It is, however, a difficult
disease to classify and does not fall into neat anatomical compartments, like its counterpart in humans and dogs.
Accurate diagnosis and appropriate classification of lymphoma requires imaging and sampling (cytology, histology
and immunohistochemistry) in order to determine the best therapeutic options to maximize survival times. The
variation in morphological appearance of lymphoma can be challenging diagnostically; other less common round cell
tumors (like mast cell neoplasia or plasma cell tumors) may appear similar. This session will review feline lymphoma
by anatomical region (abdomen, thorax, other regions) in order to discuss appropriate imaging of these regions in the
work-up of suspected cases of lymphoma.
Para-professional
Abdominal Disease
Abdominal lymphoma (alimentary, multicentric, renal) is the most common form of the disease in the cat.
Abdominal sonography is vital for staging lymphoma in the cat, particularly in the face of clinical signs (vomiting,
weight loss, diarrhea etc.), a palpable abdominal mass, or suspected multicentric disease. Abdominal radiography is
Track A
much less sensitive for abdominal staging due to the inability to remove superimposition of organs in the abdomen.
High-frequency linear ultrasound transducers (≥9MHz) are required for evaluation of the feline abdomen, particularly
the intestinal tract, and competent examination does require a large degree of operator skill. The normal wall
thickness of the segments of the feline intestines is reported at ≤2.8mm duodenum and jejunum, ≤3.2mm ileum and
2
≤1.7mm colon.
Alimentary Lymphoma
1
In cats, alimentary lymphoma is the most common form with three histological grades recognized (low,
3
intermediate and high-grades. All forms cause signs of intestinal dysfunction (e.g. weight loss, vomiting, diarrhea).
High-grade alimentary lymphoma tends to present with a mass lesion in the stomach or intestine, and often
3
extraintestinal lesions (severe lymphadenopathy) are present. A focal intestinal mass, typically hypoechoic, whose
dimensions are greater than normal intestinal wall and incorporate loss of normal wall layering, are the typical
features of high-grade lymphoma. The lesion typically is concentric. Severely enlarged, hypoechoic lymph nodes are
4
often detected close to the affected region of intestine and peritoneal effusion may be present. The mass lesion
may create focal intestinal obstruction. There may be one mass, or several mass lesions present in the intestine.
Ultrasound guided sampling of these masse cytologically is typically straightforward with reasonable operator
experience and high resolution ultrasound equipment. The author prefers to sample both the intestinal lesion/s and
abnormal lymph nodes; multiple fine needle aspirates obtained from each area to minimize the chance of placement
of the needle into the necrotic center of the mass. Attention to careful smear technique will maximize preservation of
cytological integrity. If the samples are not conclusive, surgical biopsies with histopathology and
immunohistochemistry may be required.
Low-grade alimentary lymphoma is a more of a diagnostic challenge in cats, primarily as its morphological
5
features are similar to those of inflammatory bowel disease (IBD) and can overlap normal intestine. Sonographically,
low grade alimentary lymphoma typically presents with either normal wall thickness and layering, or a mild thickening
of the walls. There may be alteration of the normal wall layering ratios with muscularis propria thickening; however
5
this finding is also a sonographic feature of inflammatory bowel disease. Zwinenberger and coworkers recently
published guidelines about alterations in wall layering, with a muscularis to submucosa ratio of greater > 1 being
indicative of an abnormal bowel segment and suggestive of disease. Associated intestinal lymph nodes, particularly
the colic node, may be mildly enlarged compared to normal cats, but do not tend to have the hypoechoic appearance
and severe enlargement of the high grade forms. Ultrasound guided needle aspirates are not indicated; full thickness
Advanced
biopsy is required to differentiate IBD from lymphoma.

Multicentric lymphoma incorporates disease in many organs, including the liver, spleen and lymph nodes.
“Typical” sonographic appearances of feline lymphoma (increased organ size and moth-eaten appearance or
nodules in the spleen; nodules, heterogeneous appearance, changes in echogenicity, increased size in the liver)
6
have been described for the liver and spleen, but unfortunately these findings are not pathognomonic, other
differentials cannot be ruled out and cytology alone has been shown to be inaccurate. Further, sonographically
7
“normal” livers and spleens may be infiltrated with lymphoma and therefore needle aspirates of these organs are
recommended for staging. There is always a chance that needle aspirates alone will not accurately reflect the
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disease in the organ (or may be non-diagnostic); in such cases, repeat sampling or biopsy may be indicated. The
more organs and sites sampled in the abdomen, the greater the chance of getting a cytological diagnosis.
Renal lymphoma is always bilateral, and it is uncommon to have renal lymphoma without involvement of
8
other organs. On clinical exam, these patients may have palpable abnormalities of the kidneys, including
enlargement or alterations in shape. Sonographically correlated appearances of renal lymphoma include hypoechoic
Generalist
subcapsular thickening and poorly defined hypoechoic nodules, but again, neither appearance is pathognomonic and
9
other differentials need to be considered. Fine needle aspirates of kidneys can be performed with a low risk of
hemorrhage.
Thoracic Disease
1, 10
Mediastinal lymphoma is much less common than alimentary forms and has a higher incidence in
Siamese and Siamese-related breeds at a considerably younger age (peak distribution of ~ 2 years) than other forms
10
of lymphoma in cats. Imaging of thoracic disease relies on both radiography and sonography, with CT also being
an excellent tool, but utilized less often. These cats typically present with pleural effusion resulting in dyspnea, and
thoracic radiographs are indicated to confirm effusion and help quantify volume. If patients are very dyspneic and
fragile stabilization with oxygen first is recommended; alternatively consider keeping the cat in sternal recumbency
and performing ultrasound of the ventral thoracic wall. Pleural effusions can be drained and the cranial mediastinum
interrogated for evidence of lymphadenopathy (hypoechoic, enlargement of lymph nodes or thymus). Ultrasound
guided needle aspirates are useful for sampling masses, and fluid analysis is also indicated. Repeating thoracic
Para-professional
radiographs after drainage may allow interrogation of the lungs, as pulmonary lymphoma, although rare, has been
11
reported.
12, 13
Intracardiac and pericardial lymphoma is being recognized with increasing frequency although are still
Track A
rare. These lesions may be detected on sonographic examination, using high-frequency linear or sector transducers.
Pericardial lymphoma tends to present with pleural effusion, marked thickening of the pericardium and pericardial
12
effusion. Antemortem diagnosis relies on fluid analysis (pleural and pericardial) or needle aspirates of the
thickened pericardium. Careful and systematic echocardiogram may be required to detect subtle structural cardiac
14
abnormalities, although failure to detect structural abnormalities does not rule out intracardiac neoplastic disease.
Lymphoma of the Head

Lymphoma affecting the head commonly involves the nasal cavity, and is less commonly reported in the
nasopharyngeal/laryngeal, ocular or neural structures. These cats will present with various clinical signs according to
the organs affected. The choice of imaging modality will depend, therefore, on the clinical signs and suspected extent
of disease. Radiography of the head is a poor choice due to its poor sensitivity for differentiating soft tissue disease.
Likewise, sonography is not likely to provide a lot of benefit for some forms of lymphoma (e.g. neural lymphoma),
although evaluation of the larynx, pharynx and retropharyngeal regions with ultrasound may allow for sampling of
masses. Advanced imaging (CT or MRI) are the tools of choice for determining the extent of structural disease,
detecting intracranial extension and assisting with sampling. MRI features of CNS lymphoma in 4 cats have been
15
described.
Lymphoma in Other Areas

Rarely, lymphoma has been reported to occur in other locations including cutaneous, skeletal muscle
1 16
locations and bone. There are no typical appearances of the disease in these organs reminding us that although
rare, clinicians may need to keep an index of suspicion for lymphoma in cases of unusual disease in the cat.
Diseases that May Mimic Lymphoma

As previously stated, unfortunately lymphoma does not have a pathognomonic appearance in any organ in
imaging modality. Astute clinicians will retain a sensible differential diagnosis list other diseases that may mimic the
appearance of lymphoma. Visceral mast cell tumors, although rare, may affect the spleen and alimentary tract;
17
diagnosis is usually straightforward with cytological evaluation. Extramedullary plasmacytoma is a rare disease in
cats but often causes a mass effect in the abdomen (hepatomegaly, splenomegaly with alterations in normal
18
echogenicity) which will mimic lymphoma, unlike other species where bone lesions predominate. Other differentials
that may appear similar to high-grade lymphoma included primary GI neoplasia (e.g. intestinal carcinoma), primary
Advanced
renal neoplasia (carcinoma), or carcinomatosis.

Non neoplastic diseases like fungal granulomatous disease may also present with imaging findings similar to
high grade lymphoma. The author has seen several cases of systemic toxoplasmosis causing large granulomatous-
like lesions and severe abdominal lymphadenopathy with peritoneal effusion in cats treated with immunosuppressive
doses of cyclosporine. Bacterial lymphadenitis, although uncommon, was detected in one aged, immunosuppressed
cat in a welfare-shelter, resulting in multifocal severe lymphadenopathy. The diagnosis was made cytologically and
the cat responded to treatment of appropriate antibiotic therapy and supportive intravenous fluid therapy. These
conditions serve to remind us that although feline lymphoma, particularly abdominal forms, is extremely common
sampling should be attempted in every patient where lymphoma is suspected.
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References
1. Sato H, Fujino Y, Chino J et al. Prognostic analyses on anatomical and morphological classifications of feline
lymphoma. J Vet Med Sci 76; 807, 2014.
2. Gogin Jm , Biller DS, Bebey BM et al. Ultrasonographic measurement of gastrointestinal wall thickness and
the ultrasonographic appearance of the ileocolic region in healthy cats. J Am Anim Hosp Assoc 36:224,
Generalist
2000.
3. Barrs
4. Penninck DG, Moore AS, Tidwell AS et al. Ultrasonography of alimentary lymphosarcoma in the cat. Vet
Radiol Ultrasound 35:299, 1994.
5. Zwingenberger AL, Marks SL, Baker TW et al. Ultrasonography evaluation of the muscularis propria in cats
with diffuse small intestinal lymphoma or inflammatory bowel disease. J Vet Intern Med 24:289, 2010.
6. Crabtree AC, Spangler E, Beard D et al. Diagnostic accuracy of free-scale ultrasonongraphy for the detection
of hepatic and splenic lymphoma in dogs. Vet Radiol Ultrasound 51;661, 2010.
7. Ballegeer EA, Forrest LJ, Dickinson RM et al. Correlation of ultrasonographic appearance of lesions and
cytological and histologic diagnoses in splenic aspirates for dogs and cats: 32 cases (2002-2005). J Am Vet
Med Assoc 230;690, 2007.
8. Moore A. Extranodal Lymphoma in the cat, prognostic factors and treatment options. J Feline Med Surg
15:379, 2013.
9. Valdes-Martinez A, Cianciolo R, Mai W. Association between renal hypoechoic subcapsular thickening and
Para-professional
lymphosarcoma in cats. Vet Radiol Ultrasound 48;357, 2007.
10. Louwerens M, London CA, Pedersen NC, et al. Feline lymphoma in the post-feline leukemia virus era. J Vet
Intern Med 19:329, 2005.
Track A
11. Brown AL, Beatty JA, Nicoll RG et al. Dyspnoea and pulmonary consolidation in a cat with T-cell lymphoma.
J Feline Med Surg 13;772, 2011.
12. Amati M, Venco L, Roccabianca R et al. Pericardial lymphoma in seven cats. J Feline Med Surg 16;507,
2014.
13. Shih JL, Breen S, Schrope DP. Cardiac involvement secondary to mediastinal lymphoma in a cat: regression
with chemotherapy. J Vet Cardiol 16:115, 2014.
14. Aupperle H, Marz I, Ellenberger C et al. Primary and secondary heart tumours in dogs and cats. J Comp
Pathol 136:18, 2007.
15. Palus V, Volk HA, Lamb CR et al. MRI features of CNS lymphoma in dogs and cats. Vet Radiol Ultrasound
53, 44, 2012.
16. Brockley LK, Heading KL, Jardine JE et al. Polyostotic lymphoma with multiple pathological fractures in a 6
month old cat. J Feline Med Surg 14;285, 2012.
17. Henry C, Herrara C. Mast cell tumors in cats: Clinical update and possible new treatments. J Fel Med Surg
15:41, 2013.
18. Mellor PJ, Haugland S, Murphy S et al. Myeloma-related disorders in cats commonly present as
extramedullary neoplasms in contrast to myeloma in human patients: 24 cases with clinical follow-up. J Vet
Intern Med 20:1376, 2006.
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CT of the Feline Head

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Introduction
The feline head is a complex anatomical structure because of its small size, complex contour and multiple
bones. Drawing useful conclusions from radiography is difficult due to the marked anatomical superimposition and
curved nature of many structures like the temporomandibular joints and the nasal cavity. Dental radiographic
systems allow for high-quality evaluation of selected teeth, but fail to capture the context of these changes in the
skull. CR and DR systems are limited in their ability to assess the nasal cavity, particularly as intra-oral projections
are not possible.
CT has revolutionized the way we approach imaging the feline head. CT allows rapid assessment (sometimes in only
seconds) of this complex anatomy; post processing provides added benefits of evaluation of the data set in multiple
planes and different windows (soft tissue vs bony). Volume rendered techniques allow for the creation of a 3D model
of the head, which can be interrogated from any perspective. The ability to share this digital data through
teleradiology allows for the assessment by those specialized in interpretation (e.g. radiologists, surgeons). In our
Para-professional
practice, radiography of the feline head has been completely superseded by CT for many years.
CT scans tend to be short; with multidetector scanners the scan times for the acquisition may be seconds.
This compares favorably to MR, where scanning acquisition times are longer (30-60 minutes, depending on the
sequences acquired).
Track A
CT Technique
Scanning with general anesthesia is generally indicated; patients are intubated but with helical scanning
systems, the acquisition time is kept to a minimum (between 5-30 seconds). It is helpful to aim for straight positioning
of the skull along the CT bed, lining the sagittal midline of the head with the middle of the patient bed. Whilst
suboptimal positioning can be corrected with post processing, to spend a few seconds setting the scan up initially will
save time afterwards, and means less work is required to make MPRs. The use of ET tubes without a metallic strip
will reduce artifacts in the scan. The cuff valve typically contains a metallic spring; ensure this is pulled cranial to the
cat’s head and out of the field of view. Anesthesia monitoring equipment like pulse oximetry probes contain metal
and can create artifacts if included in the scan; remove these from the tongue temporarily during the scan or attach to
a more caudal piece of anatomy (like a digital pad).
Many CT systems come with a patient head-rest designed for humans to use when lying on their back. Such
a head rest is typically too large for a cat.
Patient positioning: feline head CT

• Position the anesthetized cat in sternal recumbency with pelvic limbs flexed below body
• Ensure the head and neck are extended: the head can lie flat on the scanner bed, or be elevated slightly by
a foam wedge
• Ensure the sagittal midline of the skull is lined up with the midline of the patient bed.
• Ensure that the ears are level in both planes
• Position the thoracic limbs flexed next to the thoracic wall so that they are not lying next to the head, or
extend the shoulders and pull the limbs caudally so that they lie lateral to the abdomen. This will ensure that
there is no beam-hardening artifact from the bones of the front legs reducing the quality of the CT
Most CT scanners acquire a scout or topographic study first, analogous to a low-resolution digital
radiographic image in both planes (DV and lateral). This allows you to select the correct area that you wish to scan,
including collimating in to exclude superfluous areas. With the faster, more modern CT scanners, the topographic
scan may take longer than the acquisition scan.
Anesthetized cats can continue to breathe naturally throughout the acquisition of the CT scan as there will be
Advanced
little respiratory motion affecting the head and neck. There is no need to induce apnea for head scans (unlike
scanning the thorax, abdomen or spine).
In recent years the development of a protocol to allow scanning of conscious cats (the VetMousetrap-TM)
1,2
has been published. This involves placing a conscious cat in a small, space-limited acrylic (radiolucent) tubular
“box” which can be insufflated with oxygen during the scan. The size of the box precludes the patient from turning
around although some patient movement is still possible. The benefits include reducing the cost of the CT procedure
and mitigating anesthesia risks. Disadvantages include less optimal patient positioning (although this is correctable
with post processing), increased scan artifact due to patient movement during the scan and increased post
processing to realign the scan planes to normal anatomy for dorsal sagittal and transverse. The use of conscious CT
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to examine the orbital region in eleven cats using this device was compared to anesthetized CT scans concluding no
3
difference in scan quality in conscious animals. It must be noted that the CT scanner used in these studies was a 16
multislice helical system. With lower detector combinations (e.g. 4, 6 detector configurations), scan times are slightly
longer, which may result in further degradation of the image quality.
The author has not had experience using this device in practice. Whilst there are benefits to avoiding
Generalist
anesthesia, sometimes anesthesia is useful for CT of the head. In the anesthetized patient visualization of the
oropharynx during intubation, palpation of the skull (particularly after trauma) and sampling from neoplastic or
inflammation lesions at the time the scan can occur. With attention to patient alignment, the time spent post
processing the study will also be reduced.
The Use of IV Contrast

Injecting intravenous iodinated contrast agents provide improved visualization of soft tissue structures
allowing visualization of normal vascular anatomy. Detection of inflammatory or neoplastic lesions in the soft tissue
window is enhanced by the use of IV contrast. Bony lesions typically don’t benefit from the use of IV contrast. The
4
use of iodinated contrast is generally safe in well hydrated animals, but contrast is renotoxic and should be avoided
in patients with severe renal compromise who are not well-hydrated. The author’s preferred dose is 600mgI/ml.
In the case of head trauma, the administration of IV contrast may not change much, particularly if bony trauma
(fracture, luxation) is present. In cases of neoplastic or inflammatory conditions of the head, the use of contrast is
recommended. For assessment of brain disease, two scans are recommended (pre contrast, and post contrast). For
Para-professional
general head conditions not specifically relating to brain imaging, the author does not tend to perform pre-contrast
scans.
Track A
Head Trauma
CT is indicated for the assessment of any head trauma, particularly where there are concerns about
5
temporomandibular joints. Head trauma leading to fracture of the TMJ is common in cats and clinical signs of TMJ
dysfunction may occur weeks or months after the traumatic episode, secondary to complications of non-union or mal-
6
union. Fractures of the skull are more easily detected with CT than radiography and the concurrent assessment of
the brain and soft tissues is possible. Assessment of the need for surgery is possible. The ability to create 3DVR
allows for assessment of the skull and mandibles in space, and can highlight subtle differences between left and right
in the contours of fractured or damaged bones.
Nasal Cavity/Face
CT is ideal for assessing the nasal cavity of cats, and can help to differentiate rhinitis (inflammatory, fungal or
foreign body) from nasal neoplasia. The use of IV contrast is recommended in these cases. The CT may aid planning
for rhinoscopy or retropharyngeal biopsy and helps evaluate whether aggressive disease extends into the
neurocranium.
Tumors of the face including those arising from the salivary glands, retrobulbar structures, lymph nodes or
bony structures are easily detected, and the optimal site for sampling (biopsy or aspirates) can be obtained. Normal
7
reference ranges for medial retropharyngeal lymph nodes have been described with CT.
Ears
CT is an excellent non-invasive tool for evaluation of the auditory system, including assessment of external
and middle ear disease, nasopharyngeal polyps, sinonasal disease and auditory neoplasia. Auditory disease is more
common than clinical examinations suggest. One study showed one third of cats that had CT signs of middle ear
8
disease had no clinical signs of the disease indicating the good sensitivity of the modality for detecting ear disease.
Bulla effusion is present in cats with sinonasal disease with a higher incidence than cats without sinonasal disease,
9
reinforcing the anatomical proximity of the nasal cavity and middle ear through the auditory tube. Auditory neoplasia
(ceruminous gland adenocarcinoma) needs to be differentiated from non-neoplastic disease (ceruminous gland
hyperplasia or adenoma, inflammatory polyps) and CT is useful for characterizing these lesions and allowing
accurate sampling through needle aspiration. CT has proven to be an effective tool at preoperative prediction of
10
auditory nasopharyngeal polyps.
Advanced
Brain
CT of the feline brain is useful for detecting contrast-enhancing mass lesions (e.g. neoplastic lesions,
particularly those in the meninges, fungal granulomas), lesions that distort brain symmetry (alter the location of the
falx cerebri) and lesions that erode the neurocranium (bone tumors, aggressive nasal cavity disease including
extension of fungal disease). CT tends to be poorly specific for differentiating disease, and neoplastic and
inflammatory lesions may have a similar appearance. CT is less useful for the detection of isodense and poorly
enhancing brain parenchymal disease, like meningoencephalitis, some neoplastic disease (glioma) and oedema.
MRI is a superior tool for assessment of primary brain parenchymal disease.
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In conclusion, CT of the feline head has many indications (trauma, sinonasal and auditory disease, facial
distortion, neurological disease). Given the vast improvement in the quality of the information obtained by CT over
radiography, CT should be the modality of choice for imaging head disease, excluding primary neurological disease.
References
Generalist
1. Oliveira, CR, Ranallo FN, Pijanowski GJ et al. The VetMousetrap: a device for computed tomographic
imaging of the thorax in awake cats. Vet Radiol Ultrasound 52:41-2011.
2. Oliveira CR, Mitchell MA, O’Brien RT. Thoracic computed tomography in feline patients without use of
chemical restraint. Vet Radiol Ultrasound 52:368. 2011.
3. Collins SP, Matheson JS, Hamor RE et al. Comparison of the diagnostic quality of computed tomography
image of normal ocular and orbital structures acquired with and without the use of general anaesthesia in the
cat. Vet Ophthal 16:352, 2013.
4. Bettmann MA. Frequently asked questions: Iodinated Contrast Agents. Radiographics 24:S3, 2004.
5. Ariz B, Cissell DD, Vertraete FJ et al. Computed tomographic findings in dogs and cats with TMJ disorders:
58 cases (2006-2011). J Am Vet Med Assoc. 242, 69, 2013.
6. Bar-Am Y, Pollard RE, Kass PH, Verstraete FJ. The diagnostic yield of conventional radiographs and
computed tomography in dogs and cats with maxillofacial trauma. Vet Surg 37, 294, 2008.
7. Nemanic S, Nelson NC. Ultrasonography and non-contrast computed tomography of medial retropharyngeal
lymph nodes in healthy cats. Am J Vet Res 73: 1377, 2012.
Para-professional
8. Shanaman M, Sieler G, Holt DE. Prevalence of clinical and subclinical middle ear disease in cats undergoing
computed tomography scans of the head. Vet Radiol Ultrasound 53, 76, 2012.
9. Detweiler DA, Johnson LR, Kass PH, Wisner ER. Computed tomographic evidence of bulla effusion in cats
Track A
with sinonasal disease: 2001-2001. J Vet Intern Med 20, 1080, 2006.
10. Oliveira CR, O’Brien RT, Matteson JS, Carrera I. Computed tomographic features of nasopharyngeal
polyps. Vet Radiol Ultrasound 53, 406, 2012.
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Oral Tumors in Cats: Hope for the Future

Annette Smith, DVM, MS, DACVIM (Oncology & SAIM)
Generalist
Introduction
In cats, non-malignant oral masses can include epulides, eosinophilic granuloma complex and
nasopharyngeal polyps. Fibrosarcomas also occur, as well as other tumor types, but by far the most common
malignant oral tumor is squamous cell carcinoma (SCC), which carries a guarded to poor prognosis. A better
understanding of this frustrating disease might help to identify better treatment options.
Etiology
Some factors that have been associated with the development of oral squamous cell carcinomas include the
1
use of flea collars, the feeding of canned food (tuna, in particular), and potentially exposure to second-hand smoke.
2
Tumors in cats exposed to cigarettes were much more likely to have p53 (tumor suppressor) mutations. Cats that
eat canned food may have more tartar build-up/gingivitis, and chronic inflammation is a proposed underlying cause
for many cancer types. Differences in nutrients within diets might also play a role. The use of flea collars is likely
Para-professional
related to long-term exposure to pesticides, which are more likely to be ingested by a cat due to their grooming
behavior, which may generally explain the higher incidence of oral tumors in cats compared to other species.
3
Track A
Malignant oral tumors are found in older cats of any gender and breed. Unless an owner is conscientious
about brushing the cat’s teeth or is giving frequent oral medications, it is rare to notice a small oral mass, especially
under the tongue or in the caudal part of the mouth. As an oral mass enlarges, it may cause a foul odor, discharge or
bleeding from the mouth and/or nose, excessive drooling, facial swelling, or difficulty prehending or chewing food. In
cats, weight loss and depression/lethargy may be the presenting clinical sign. Veterinarians or technicians may more
commonly identify an oral mass on a routine physical examination or when performing a dental prophylaxis. Routine
dental radiography also helps to identify significant bony lysis that may be present without obvious intraoral disease.
When masses or seen, they should be biopsied; when loose teeth are found in the absence of significant dental
disease, a biopsy of the tooth roots, underlying gum and bone should be considered.
Diagnostics and Staging

For all older cats that present for signs of illness, diagnostics are initially a complete physical examination,
CBC/serum chemistry panel/urinalysis, T4, and retroviral testing. Hypercalcemia has been associated with oral
4
squamous cell carcinoma as a paraneoplastic syndrome. Once neoplasia is diagnosed through cytology or biopsy of
a mass, 3-view chest radiographs are generally recommended, although in oral SCC, the incidence of tumor spread
3
at diagnosis is quite low. From a general health perspective, thoracic screening may identify other underlying
disease. Mandibular lymph node aspirates should also be performed; again, a low-yield procedure, but when
metastasis is present, there is concern for a more aggressive tumor course. Abdominal ultrasound is not
recommended from a tumor-staging standpoint, but might also be helpful in assessing overall patient health.
Management & prognosis

Overall, prognosis is poor for cats with oral SCC, whether in either a general practice or specialty hospital
5,6
setting. Reported median survival times range from 2-6 months, with one-year survivals usually less than 10%,
although some exceptions exist. Treatment options must be tailored to the individual patient for the best chance of an
optimal outcome.
Surgery
The rule is: “if it’s on the gum, it’s in the bone”. For complete surgical margins, some segment of the
underlying bone must be removed with malignant or invasive benign lesions. Shaving, cautery, and lasering of the
surgical site generally do not provide any prevention of recurrence.
Advanced
For cats with oral fibrosarcoma of the mandible, median survival time was more than 28 months after a
7
mandibulectomy. Squamous cell carcinoma, however, is usually less amenable to surgical resection. Those that are
involving the bony structures might be more suited to surgical removal, depending on the location and extent of
4,7
disease. Cats treated with mandibulectomy +/- radiation therapy lived for a median of 11-14 months. Completeness
of excision is likely critical for long-term disease-free survival, since many cats die of local recurrence. More rostral
tumors had a better prognosis (likely reflecting an earlier seen, smaller mass, and easier removal) of around 30
7
months. Those tumors that are expansile and discrete, rather than ulcerated/lytic/invasive, are better surgical
candidates.
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Patient and client selection is extremely important, since cats may require feeding tube support for up to 4
7
months, or even life-long, following surgery. Those cats with large surgeries (more than 50% of the mandible
removed) were much more likely to require long-term nutritional support. With that said, owners that elected surgery
and feeding tube placement were pleased with their choice. Pre-operative owner counseling with pictures and
sometimes contacts with clients whose pets have undergone similar procedures help to prepare owners for a
Generalist
decision as to whether to have this procedure performed.
Radiation Therapy
Radiation therapy is generally considered ineffective as a solitary treatment for most cats with SCC; median
8,9
survival times are measured in weeks to a few months. Radiation sensitizers, including etanidazole, gemcitabine,
mitoxantrone, and carboplatin have been used, but generally have not improved the median survival time beyond 6
10-13
months. However, for those few patients that do have a complete response of their tumor, survival times can be
9
prolonged, closer to one year. Discussion with the owner about the usual poor outcome, but occasional good
responses, weighed against treatment costs and time, can help them to make an informed decision about whether to
incorporate radiation into the treatment plan. Patients with exophytic disease that can be surgically debulked and
reduced to microscopic disease may respond more favorably to radiation treatment. The use of stereotactic radiation
approaches have not been fully explored for this disease, and may improve responses, decrease the potential for
side effects, and minimize anesthesia and hospital stays.
Side effects associated with radiation therapy include mucositis, dermatitis, hair loss, leukotrichia, oronasal
Para-professional
fistulas, and occasional fibrosis. Cats in general appear to be more resistant to radiation-induced effects, but
anything that might impact the cat’s quality of life and decrease appetite should be considered. Feeding tube support
may be necessary to maintain nutrition during the period of multiple anesthesias for radiation therapy and possible
Track A
oral discomfort.
Chemotherapy
Chemotherapy has been considered ineffective in the management of feline oral SCC, except in the context
14
of radiosensitization (see above). Liposome-encapsulated cisplatin did not result in any responses in 18 cats.
Piroxicam was not found to induce remission in any of 13 patients, which is unsurprising, given the lack of the target,
15,16 5
COX2 expression, in this tumor. However, NSAIDs may provide some palliation, thus prolonging survival times.
Palladia™ (toceranib phosphate) in off-label use, has been given to feline patients, with responses in some cats with
17
oral SCC. One patient had a complete remission, and approximately 50% had stable disease, some lasting for
several months. The drug was relatively well-tolerated at dosages ranging from 1.67-3.95 mg/kg (median 2.8 mg/kg)
given primarily every-other-day, with a side effect profile that primarily reflected gastrointestinal toxicity (anorexia,
vomiting, diarrhea) and liver enzyme elevation. Anecdotal reports of success have also been reported with bleomycin
alternating with methotrexate.
Supportive Care
Pain control is important in managing these patients. NSAIDs are usually the basis of any pain management
protocol. However, NSAID use in cats, especially long-term, can carry significant side effects, and will often require
off-label use. Weighing risks and benefits will be important for each patient. Careful monitoring of renal function,
assessment of ulceration potential and liver effects is needed when using these drugs. Opiates are usually added as
the second-line pain management drug, and adjuvant analgesics such as amantadine, gabapentin, and tricyclic
antidepressants can also be used. Pamidronate has been used in other species to palliate bone pain, with some
success. Secondary infections can be controlled with antibiotics.
Nutritional support is also important in cats. Initial measures such as giving more nutrient-dense foods, more
palatable foods, warming foods to stimulate olfaction, and maintaining hydration may be helpful in early stages. The
use of appetite stimulants, such as mirtazapine and cyproheptadine can also support food intake. However,
mechanical difficulties in prehending, chewing, and swallowing may be the primary culprit in weight loss in many
patients with an oral mass. Bypassing the oral cavity may be the only way to adequately support nutrition; therefore
the use of a feeding tube should be considered. However, a careful conversation with the owner prior to placement
should occur regarding goals and criteria for assessing quality of life. A feeding tube in an end-stage cancer patient
may not be warranted, as opposed to a relatively short-term feeding tube in the peri-operative period, especially in
Advanced
the case of curative surgery.
Future Directions
Since Palladia™ has been proposed to have radiation-sensitizing effects; its use in conjunction with radiation
therapy might provide some benefit. A prospective, multi-institutional clinical trial investigating Palladia™ as a single
agent, or in conjunction with radiation therapy has been ongoing, supported by Zoetis (then Pfizer Animal Health).
The identification of tumor targets allows for the design of more effective drugs, and can also allow for more
personalized treatment plans. By identifying tumors that carry a certain target, we can choose a drug that is more
likely to have a clinical effect. With that in mind, an ongoing research project funded by the Winn Feline Foundation
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has investigated the presence of receptors in feline oral SCC (c-kit/stem-cell factor receptor/CD117, PDGFRβ, and
VEGFR3) that are targets of Palladia™. Previous studies have looked at EGFR (epidermal growth factor receptor),
18,19,20
and found expression in the majority of tumors and correlated expression to survival. Another clinical trial that
has been completed and is in the data-analysis phase includes gene therapy against CK2 delivered in a nanocapsule
(University of Tennessee). Further information about ongoing clinical trials can be found at www.vetcancertrials.org
Generalist
References
1. Bertone ER, Snyder LA, Moore AS, et al. Environmental and lifestyle risk factors for oral squamous cell
carcinoma in domestic cats. J Vet Intern Med 2003;17:557.
2. Snyder LA, Bertone ER, Jakowski RM, et al. p53 expression and environmental tobacco smoke exposure in
feline oral squamous cell carcinoma. Vet Pathol 2004;41:209.
3. Liptak JM, Withrow SJ. Cancer of the gastrointestinal tract: Oral tumors. In Withrow SJ, Vail DM, Page RL,
th
eds. Withrow & MacEwen’s Small Animal Clinical Oncology, 5 ed. Saunders Elsevier 2013, pp 381-398.
4. Hutson CA, Willauer CC, Walder EJ, et al. Treatment of mandibular squamous cell carcinoma in cats by use
of mandibulectomy and radiotherapy: seven cases (1987-1989). J Am Vet Med Assoc 1992;201:777.
5. Hayes AM, Adams VJ, Scase TJ, et al. Survival of 54 cats with oral squamous cell carcinoma in United
Kingdom general practice. J Small Anim Pract 2007;48:394.
6. Reeves NCP, Turrel JM, Withrow SJ. Oral squamous cell carcinoma in the cat. J Am Anim Hosp Assoc
1993;29:438.
Para-professional
7. Northrup NC. Selting KA. Rassnick KM. et al. Outcomes of cats with oral tumors treated with
mandibulectomy: 42 cases. J Am Anim Hosp Assoc 2006;42(5):350-60.
8. Bregazzi VS, LaRue SM, Powers BE, et al. Response of feline oral squamous cell carcinoma to palliative
Track A
radiation therapy. Vet Radiol Ultrasound 2001;42:77.
9. Fidel JL, Sellon RK, Houston RK, et al. A nine-day accelerated radiation protocol for feline squamous cell
carcinoma. Vet Radiol Ultrasound 2007;48:482.
10. Evans SM, LaCreta F, Helfand S, et al. Techniques, pharmacokinetics, toxicity, and efficacy of intratumoral
etanidazole and radiotherapy for treatment of spontansous feline oral squamous cell carcinoma. Int J Radiat
Oncol Biol Phys 1991;20:703.
11. Personal communication: LaRue SM, Vail DM, Ogilvie GK, et al. Shrinking-field radiation therapy in
combination with mitoxantrone chemotherapy for the treatment of oral squamous cell carcinoma in the cat.
Vet Cancer Soc Proc 1991;99.
12. Jones PD, de Lorimier LP, Kitchell BE, et al. Gemcitabine as a radiation sensitizer for nonresectable feline
oral squamous cell carcinoma. J Am Anim Hosp Assoc 2003;39:463.
13. Fidel J, Lyons J, Tripp C, et al. Treatment of oral squamous cell carcinoma with accelerated radiation therapy
and concomitant carboplatin in cats. J Vet Intern Med 2011;25:504.
14. Fox LE, Rosenthal RC, King RR, et al. Use of cis-bis-neodecanoato-trans-R,R-1,2-diaminocyclohexane
platinum (II), a liposomal cisplatin analogue, in cats with oral squamous cell carcinoma. Am J Vet Res
2000;61:791.
15. Hayes A, Scase T, Miller J, et al. COX-1 and COX-2 expression in feline oral squamous cell carcinoma. J
Comp Pathol 2006;135:93.
16. DiBernardi L, Dore M, Davis J, et al. Study of feline oral squamous cell carcinoma: potential target for
cyclooxygenase inhibitor treatment. Prostaglandins Leukot Essent Fatty Acids 2007;76:245.
17. Personal communication: Hohenhaus A, Henry C, Greene S, et al. Biological activity and adverse event
profile in cats treated with toceranib phosphate. Vet Cancer Soc Proc 2010;64.
18. Looper JS, Malarkey DE, Ruslander D, et al. Epidermal growth factor receptor expression in feline oral
squamous cell carcinomas. Vet Comp Oncol 2006;4(1):33-40.
19. Bergkvist GT, Argyle DJ, Morrison L, et al. Expression of epidermal growth factor receptor (EGFR) and Ki67
in feline oral squamous cell carcinomas (FOSCC). Vet Comp Oncol 2011;9(2):106-17.
20. Yoshikawa H, Ehrhart EJ, Charles JB, et al. Immunohistochemocal characterization of feline oral squamous
cell carcinoma. Am J Vet Res 2012;73(11):1801-6.
NOTES:
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Management of Feline Large-cell Lymphoma Updates

Annette Smith, DVM, MS, DACVIM (Oncology & SAIM)
Generalist
Introduction
Feline lymphoma encompasses a variety of presentations, primarily based on anatomic site and the cellular
phenotype. Overall, small-cell lymphoma appears to carry a more favorable prognosis, and responds to a less
1-3
aggressive chemotherapy protocol incorporating corticosteroids and chlorambucil. Large-cell lymphoma, however,
remains a challenging disease to treat, with the ideal chemotherapy regimen in cats not defined.
Etiology
4,5
FeLV/FIV
With the decreasing incidence of FeLV infection, the typical presentation of lymphoma has shifted from the
young infected cat with a mediastinal mass to an older, serologically negative patient with (usually small-cell)
gastrointestinal involvement. FeLV/FIV infections remain an important cause of lymphoma, and their presence may
negatively impact prognosis, especially for cats that are having clinical signs related to their infections beyond their
Para-professional
lymphoma diagnosis.
Gender and Breed

5-7
Siamese cats may carry a genetic predisposition. Although inconsistent, there are reports that males are
Track A
6,7
overrepresented.
Other Related Factors

8
Exposure to tobacco smoke appears to increase the risk of lymphoma development. Any exposure imparted
a relative risk of 2.4, while five or more years of exposure increased the risk to 3.2 over baseline.
Immunosuppression related to renal transplantation has also been associated with increased lymphoma risk, with
9,10
nearly 10% of cats that were receiving immunosuppressive drugs post-transplant developing lymphoma. Various
genetic aberrations associated with cancer development have also been associated with the development of
lymphoma.
Presenting clinical signs are related to location of the primary tumor, causing organ infiltration and
dysfunction or a space-occupying mass. Other presenting signs can be related to generalized malaise, depression,
inappetance, or weight loss. Physical examination can identify lymphadenopathy or organomegaly.
4
Diagnostics and Staging
Usually, cytology from a fine needle aspirate of the affected organ is adequate for diagnosis of large-cell
lymphoma. Occasionally, it is difficult for a cytologist to distinguish a reactive or inflammatory process from
lymphoma, in which case further diagnostics may be necessary. Techniques such as flow cytometry and PARR
(PCR for antigen receptor rearrangement) can be performed on cytologic samples. However, they may not be as
specific and sensitive as we would like in cat samples. PARR is reportedly 89% sensitive and 80% specific in feline
11,12
T-cell lymphoma, but only 60% sensitive and 70% specific for feline B-cell lymphoma. Another test, the VDI
TKFeline, is also available and purports to be able to differentiate inflammatory bowel disease from lymphoma.
However, most oncologists are going to be reluctant to institute cytotoxic chemotherapy without a tissue sample
13
diagnosis, since these results are only reported on the company website, without a peer-reviewed publication. A
lymph node excision or core biopsy of the affected tissue should be strongly considered in equivocal cases, and
remains the gold standard of diagnosis.
For all older cats that present for signs of illness, diagnostics are initially a complete physical examination,
CBC/serum chemistry panel/urinalysis, T4, and retroviral testing. For lymphoma, further testing should include
imaging of the area of interest (such as CT scan for nasal lymphoma, MRI for CNS lymphoma, abdominal ultrasound
Advanced
for GI lymphoma, etc.). Further complete staging would include sampling of regional lymph nodes, thoracic
radiography (usually two views are adequate), abdominal ultrasonography, and bone marrow aspiration. Complete
staging is particularly important when determining local vs. systemic disease, since recommendations for therapy
and prognosis may vary depending on the extent of disease.
General Management
Surgery
Lymphoma is not typically considered a surgical disease; its use is primarily for diagnosis. The exception
may be some localized, small-cell variants.
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Radiation Therapy
Radiation therapy has been used in some forms of lymphoma, either as a primary treatment in localized
disease, or in conjunction with chemotherapy as a consolidation strategy.
Generalist
Chemotherapy
Combination chemotherapy protocols (CHOP-based; Cyclophosphamide, Hydroxydaunorubicin/doxorubicin,
Oncovin/vincristine, Prednisone/prednisolone) have been assumed to be the ideal first-line therapy in cats with large-
cell lymphoma, based on response rates in other species and indications that long-term survival is better with the
4
incorporation of doxorubicin. However, the ideal therapeutic regimen for cats has not been completely defined. Most
studies are small and have historically included both small- and large-cell subtypes, as well as a variety of anatomic
sites, which inherently carry a different behavior and prognosis. Shorter, discontinuous protocols have been adopted
14-16
in canine patients, and may also be useful in our feline patients.
For clients that are reluctant to pursue a combination chemotherapy protocol, corticosteroids alone are a
reasonable palliative choice. Doxorubicin as a single-agent is often considered our most active chemotherapy agent
in lymphoma, but may not show the high response rates and relatively long control in cats, based on some very small
17,18
studies. L-asparaginase, as well, is not as effective in our feline patients, with only a 30% response rate reported
19
in a study of 13 cats. CCNU should also not be offered as an optimal first-choice drug, since it has only been
20,21
reported to cause partial remissions.
Para-professional
Overall response rate in cats with lymphoma treated with chemotherapy is 50-80%, with a median survival
4
time of around 6 months. Approximately one-third of patients do not respond to therapy, with survival times
measured in weeks. Multiple studies with a COP or CHOP protocol have shown a “tail” in the Kaplan-Meier survival
Track A
7,14-16,22-27
curve, in which a subset of patients achieve long-term survivals. Prognosis has consistently been
associated with the response of the tumor to treatment, with complete responders having improved survival times
compared to those with only a partial response. In patients that achieve a CR, approximately 1/3 will remain disease-
free at 2-3 years. Unfortunately, identification of which patients will be complete responders pre-treatment is
problematic.
Rescue treatments (the administration of not-previously-used drugs when the patient relapses after initial
therapy) are also not well-defined in cats. CHOP can be re-administered in the case of relapse, if the patient has
been off-therapy for a period of 1-2 months. Cumulative doxorubicin cardiotoxicity is less problematic in cats,
although renal toxicity is more frequent, so renal monitoring is important. If COP was used initially, doxorubicin can
28
be used as a rescue agent, although response rates are reportedly only 20% with this approach. MOPP
(mechlorethamine, vincristine, procarbazine, and prednisone) and CCNU (50-60 mg/m2 given PO q 3-6 weeks) have
been used with some success by the presenter, once CHOP therapy is ineffective. Other drugs that could be
considered include mitoxantrone and vinblastine.
Assessment of Response
Throughout therapy, because of the impact of achieving a complete remission on prognosis and treatment
decisions, assessment of response is very important. Continuation of an ineffective protocol allows progression of the
disease, risks side effects to no benefit to the patient, and may deplete owner resources and decrease their
willingness to perform rescue treatment. When possible, objective measures such as weight, measurements of tumor
size, repeated FNA cytology, etc., should be used to determine remission status. However, multiple sedated
examinations, imaging, and sampling can be stressful for the patient, as well as the owners in terms of financial and
time commitments. For this reason, remission of clinical signs or improvement in patient quality of life are often
substituted as assessments of response. Serial measurement of VDI TKFeline, with a demonstrated decrease in
values after successful treatment, may also provide a non-invasive, indirect marker of disease remission or
13
progression, although this remains to be proven.
Supportive Care
Nutritional support, pain control, hygiene, treatment of concurrent disease, etc. should all be considered in
the management of lymphoma patients. When clinical signs occur, a determination of whether the cause is
progression of the lymphoma, a treatment-related side effect, or another cause will help to guide therapeutic choices.
Advanced
Presenter’s Approach
It is my preference to use a 12-week, multi-agent protocol, with discontinuation of treatment and every 4-6
week monitoring if the patient achieves a complete remission. This limits the number of patient visits, the time
commitment for the owner, potentially minimizes treatment toxicity, and identifies early which patients will be
responders, which decreases costs and allows owners to make informed decisions about continuation of treatment.
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Response/Prognosis Based on Anatomic Site
Intra-abdominal Lymphoma (primarily gastrointestinal)
16,29
Median survival times generally range from 45-100 days with chemotherapy, with large-granular-
16,30,31
lymphoma variants usually only achieving a 30% response rate and a median survival of only 1-2 months. The
addition of radiation therapy as a rescue or consolidation protocol might provide survival benefits for some
Generalist
32,33
patients.
Mediastinal Lymphoma
Usually associated with FeLV infection in young cats, reported median survival times for cats with cranial
4,23
mediastinal lymphoma are 2-3 months. Young uninfected Siamese cats, however, have a median survival of
25
around 9 months with chemotherapy treatment.
Intranasal Lymphoma
For intranasal lymphoma, radiation therapy, with total doses in excess of 32 Gy, is the treatment of choice for
disease confined to the nasal cavity, with complete responses occurring in 75-90% of patients for a median survival
34-36
time of 1.5-3 years. For those with systemic involvement, radiation may be used more palliatively, although
chemotherapy alone can result in long-term survivals (median of approximately 2 years) in the 75% of patients that
achieve a complete response. For those that do not respond completely to chemotherapy and/or radiation, median
36,37
survival times are usually less than 6 months.
Para-professional
Nodal Lymphoma
A variant of lymph node involvement, usually confined to the head and neck region, is known as Hodgkin-like
Track A
lymphoma and is characterized by a histologic description of T-cell-rich, B-cell lymphoma and Reed-Sternberg-like
38,39
cells. Localized therapy with surgery can provide long-term survival, although relapse is common. Although
unproven, the addition of chemotherapy may help to prevent recurrence.
Renal Lymphoma
Treatment with chemotherapy can result in long survival times, with one study reporting a median survival
24 37
time of 396 days in 11 cats. A second study reported a median survival time of 212 days for complete responders.
16
In a more recent study, the median survival time was 27 days in 9 cats.
CNS Lymphoma
Occasional patients will achieve a durable response to treatment with a median survival of 480 days for
37 40,41
complete responders, but the majority will not respond, with a median survival time of 1-2 months.
Laryngeal/Tracheal Lymphoma
More than 90% of patients will respond to chemotherapy, but the reported median survival time is around 5-6
37
months.
Future Treatment Options

Recent approvals of monoclonal antibody drugs in dogs, similar to treatments that have changed the
paradigm in human medicine, generate hope that feline monoclonal antibodies that would improve therapeutic
outcome may also be on the horizon.
25-week CHOP-based protocol
Treatment week 1 2 3 4 6 7* 8 9 11 13* 15 17 19 21* 23 25

Drug
L-asparaginase X
Vincristine X X X X X X X X
Cyclophosphamide X X X X
Doxorubicin X X X X
Advanced
Prednisone/ Beginning week one, 2 mg/kg PO q 24 hours x 2 weeks, then 1 mg/kg PO q 24 hours x 2
prednisolone weeks, then 1 mg/kg every other day continuously
L-asparaginase 400 U/kg SQ
Vincristine 0.5-0.7 mg/m2 IV
Cyclophosphamide 200 mg/m2 IV
Doxorubicin 25 mg/m2 IV
*Cytosine arabinoside 600 mg/m2 divided SQ twice daily over two days is substituted in renal or CNS lymphoma
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12-week CHOP-based protocol
Treatment week 1 2 3 4 5* 6 7 8* 9 10 11* 12

Drug
+/- L-asparaginase X
Generalist
Vincristine X X X X
Cyclophosphamide X X X X
Doxorubicin X X X X
Prednisone/ Beginning week one, 2 mg/kg PO q 24 hrs x 2 weeks,
prednisolone then 1 mg/kg every other day continuously
L-asparaginase 400 U/kg SQ
Vincristine 0.5-0.7 mg/m2 IV
Cyclophosphamide 200 mg/m2 PO (usually one 50 mg capsule)
Doxorubicin 20 mg/m2 IV over 20 minutes through a well-placed catheter, diluted to 0.5 mg/mL in saline,
premedicated 20 minutes prior with Cerenia 2 mg/kg SQ and dexamethasone 0.1 mg/kg SQ
*Cytosine arabinoside 600 mg/m2 divided SQ twice daily over two days is substituted in renal or CNS lymphoma
References
Para-professional
1. Lingard AE, Briscoe K, Beatty JA, et al. Low-grade alimentary lymphoma: clinicopathologic findings and
response to treatment in 17 cases. J Feline Med Surg 2009;11:692-700.
2. Kiselow MA, Rassnick KM, McDonough SP, et al. outcome of cats with low-grade lymphocytic lymphoma: 41
cases (1995-2005). J Am Vet Med Assoc 2008;232:405-410.
Track A
3. Stein TJ, Pellin M, Steinberg H, et al. Treatment of feline gastrointestinal small-cell lymphoma with
chlorambucil and glucocorticoids. J Am Anim Hosp Assoc 2010;46:413-417.
4. Vail DM. Feline lymphoma and leukemia. In Withrow SJ, Vail DM, Page RL, eds. Withrow & MacEwen’s
th
Small Animal Clinical Oncology, 5 ed. Saunders Elsevier 2013, pp 638-653.
5. Louwerens M, London CA, Pedersen NC, Lyons LA. Feline lymphoma in the post-feline leukemia virus era.
Journal of Veterinary Internal Medicine 2005;19(3):329-35.
6. Gabor LJ, Malik R, Canfield PJ, Clinical and anatomical features of lymphosarcoma in 118 cats. Aust Vet J
1998;76:725-732.
7. Vail SM, Moore AS, Ogilvie GK, et al. Feline lymphoma (145 cases): proliferation indices, CD3
immunoreactivity, and their association with prognosis in 90 cats receiving therapy. J Vet Intern Med
1998;12:349-354.
8. Bertone ER, Snyder LA, Moore AS. Environmental tobacco smoke and risk of malignant lymphoma in pet
cats. Am J Epidemiol 2002;156:268-273.
9. Schmeidt CW, Grimes JA, Holzman G, et al. Incidence and risk factors for development of malignant
neoplasia after feline renal transplantation and cyclosporine-based immunosuppression. Vet Comp Oncol
2009;7:45-53.
10. Wooldridge JD, Gregory CR, Matthews KG, et al. The prevalence of malignant neoplasia in feline renal-
transplant recipients. Vet Surg 2002;31:94-97.
11. Moore PF, Woo JC, Vernau W, et al. Characterization of feline T cell receptor gamma (TCRG) variable
region genes for the molecular diagnosis of feline intestinal T cell lymphoma. Vet Immunol Immunopathol
2005;106:167-178.
12. Werner JA, Woo JC, Vernau W, et al. Characterization of feline immunoglobulin heavy chain variable region
genes for the molecular diagnosis of B-cell neoplasia. Vet Pathol 2005;42:596-607.
13. Schleis SE. Cancer screening tests for small animals. In Smith AN, ed. Advances in Veterinary Oncology.
VetClinics of NA: Sm Anim Pract 2014;44(5): 871-881.
14. Simon D, Eberle N, Laake-Singe L, Nolte I. Combination chemotherapy in feline lymphoma: treatment
outcome, tolerability, and duration in 23 cats. J Vet Intern Med 2008; 22(2):394-400.
15. Limmer S, Eberle N, Nerschbach V, et al. Treatment of feline lymphoma using a 12-week, maintenance-free
combination chemotherapy protocol in 26 cats. Vet Comp Oncol 2014; DOI: 10.1111/vco.12082
16. Collette SA, Frazier SA, Chon EM, et al. Treatment of feline intermediate to high grade lymphoma with a
Advanced
modified University of Wisconsin-Madison protocol: 119 cases (2004-2012). Accepted Vet Comp Oncol
5/7/2015.
17. Peaston AE, Maddison JE. Efficacy of doxorubicin as an induction agent for cats with lymphosarcoma. Aust
Vet J 1999;77:442-444.
18. Kristal O, Lana SE, Ogilvie GK, et al. Single-agent chemotherapy with doxorubicin for feline lymphoma: a
retrospective study of 19 cases (1994-1997). J Vet Intern Med 2001;15:125-130.
19. LeBlanc AK, Cox SK, Kirk CA, et al. Effects of L-asparaginase on plasma amino acid profiles and tumor
burden in cats with lymphoma. J Vet Intern Med 2007;21:760-763.
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20. Rassnick KM, Gieger TL, Williams LE, et al. Phase I evaluation of CCNU (lomustine) in tumor-bearing cats. J
Vet Intern Med 2001;15:196-199.
21. Fan TM, Kitchell BE, Dhaliwal RS, et al. Hematologic toxicity and therapeutic efficacy of lomustine in 20
tumor-bearing cats: critical assessment of a practical dosing regimen. J Am Anim Hosp Assoc 2002;38:357-
363.
Generalist
22. Cotter SM. Treatment of lymphoma and leukemia with cyclophosphamide, vincristine, and prednisone: II.
Treatment of Cats. Journal of the American Animal Hospital Association 1983;19:166-172.
23. Jeglum KA, Whereat A, Young K. Chemotherapy of lymphoma in 75 cats. Journal of the American Veterinary
Medical Association 1987;190(2):174-8.
24. Mooney SC, Hayes AA, MacEwen EG, et al. Treatment and prognostic factors in lymphoma in cats: 103
cases (1977-1981). J Am Vet Med Assoc 1989;194(5):696-702
25. Teske E, van Straten G, van Noort R, Rutteman GR. Chemotherapy with cyclophosphamide, vincristine, and
prednisolone (COP) in cats with malignant lymphoma: new results with an old protocol. J Vet Intern Med
2002; 16(2):179-186.
26. Taylor SS, Goodfellow MR, Browne WJ, Walding B, Murphy S, Tzannes S, et al. Feline extranodal
lymphoma: response to chemotherapy and survival in 110 cats. J Sm Anim Pract 2009;50(11):584-92.
27. Waite AH, Jackson K, Gregor TP, Krick EL. Lymphoma in cats treated with a weekly cyclophosphamide-,
vincristine-, and prednisone-based protocol: 114 cases (1998-2008). J Am Vet Med Assoc.
2013;242(8):1104-9.
Para-professional
28. Oberthaler KT, Mauldin E, McManus PM, et al. Rescue therapy with doxorubicin-based chemotherapy for
relapsing or refractory feline lymphoma: a retrospective study of 23 cases. J Feline Med Surg 2009;11:259-
265.
Track A
29. Mahony OM, Moore AS, Cotter SM, et al. Alimentary lymphoma in cats: 28 cases (1988-1993). J Am Vet
Med Assoc 1995;207:1593-1598.
30. Krick EL, Little L, Patel R, et al. Description of clinical and pathological findings, treatment, and outcome of
feline large granular lymphocyte lymphoma (1996-2004). Vet Comp Oncol 2008;6:102-111.
31. Roccabianca P, Vernau W, Caniatti M, et al. Feline large granular lymphocyte (LG) lymphoma with
secondary leukemia: primary intestinal origin with predominance of a CD3/CD8(alpha)(alpha) phenotype. Vet
Pathol; 2006;43:15-28.
32. Williams LE, Pruitt AF, Thrall DE. Chemotherapy followed by abdominal cavity irradiation for feline
lymphoblastic lymphoma. Vet Radiol Ultrasound 2010;51:681-687.
33. Parshley DL, LaRue SM, Kitchell B, et al. Abdominal irradiation as a rescue therapy for feline gastrointestinal
lymphoma: a retrospective study of 11 cats (2001-2008). J Feline Med Surg 2011;13:63-68.
34. Elmslie RE, Ogilvie GK, Gillette EL, et al. Radiotherapy with and without chemotherapy for localized
lymphoma in 10 cats. Vet Radiol UItrasound 1991;32:277-280.
35. Sfiligoi GA, Theon AP, Kent MS. Response of 19 cats with nasal lymphoma to radiation therapy and
chemotherapy. Vet Radiol Ultrasound 2007;48:388-392.
36. Haney SM, Beaver L, Turrel J, et al. Survival analysis of 97 cats with nasal lymphoma: a multi-institutional
retrospective study (1986-2006). J Vet Intern Med 2009;23:287-294.
37. Taylor SS, Goodfellow MR, Browne WJ, et al. Feline extranodal lymphoma: response to chemotherapy and
survival in in 110 cats. J Sm Anim Pract 2009;50:584-592.
38. Day MJ, Kyaw-Tanner M, Silstone MA, et al. T-cell-rich B-cell lymphoma in the cat. J Comp Pathol
1999;120:155-167.
39. Walton RM, Hendrick MJ. Feline Hodgkin’s-like lymphoma: 20 cases (1992-1999). Vet Pathol 2001;38:504-
511.
40. Troxel MT, Vite CH, Van Winkle TJ, et al. Feline intracranial neoplasia: retrospective review of 160 cases
(1985-2001). J Vet Intern Med 2003;17:850-859.
41. Marioni-Henry K, Van Winkle TJ, Smith SH, et al. Tumor affecting the spinal cord of cats: 85 cases (1980-
2005). J Am Vet Med Assoc 2008;232:237-243.
NOTES:
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Track A Generalist
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MRI & CT for Feline Practitioners

Generalist
Introduction
Computed tomography (CT) and magnetic resonance imaging (MRI) greatly enhance the diagnostic
possibilities of the feline practitioner. They offer superior contrast resolution (capacity of a system to accurately
represent differences in tissue) compared to radiology. In particular, with these advanced imaging techniques it is
possible to differentiate between various types of soft tissues. Both modalities are cross-sectional imaging
techniques; this means that the body can be examined in slices, thereby eliminating the disadvantage of
superimposition which is found in conventional radiography. Each image represents a slice of the body composed of
small cubical sections (voxels) filling a matrix which is displayed on a flat monitor as a matrix of pixels.
CT is based on the same physical principle as radiography (attenuation of the x-ray beam) and as a result it can
detect only changes in the density of a tissue. MRI is based on tissue hydrogen content, therefore can detect tissue
biochemical and biophysical changes secondary to disease.
Para-professional
Computed Tomography
In the early days of CT, it would take several minutes to acquire and reconstruct a single CT image.
Technological developments have moved fast and with the introduction of multirow detector imaging, it is now
possible to generate images in a fraction of second. The most recent scanners (320-slice scanner) can complete an
entire body scan (human) in three seconds. A 320-slice volume scan offers 16 cm of imaging area in one rotation;
this allows an image of the entire heart during one phase rather than taking several images and stitching them
together. A fast scanner improves diagnostic ability, in particular with regard to angiography studies. In the veterinary
practices offering CT capabilities, a great range of CT scanners (usually from 2- up to 64-slices) can be found.
Motion artefact affects image quality; this artefact is often seen in thoracic images acquired with slow (single and dual
slice) scanners.
With the traditional slice-by-slice (sequential or axial) mode the body is imaged by acquiring consecutive
separate slices of the body, however, because of uncontrollable motion (e.g. peristalsis, breathing) gaps can be
created between one structure and the other.
With helical (or spiral) mode the table advances as the tube rotates around the patient, the images are
acquired without interruption and at a greater speed, generating a data volume rather than a single slice. This
eliminates the gaps encountered with slice-by-slice mode. Steps are often encountered when viewing 3D
reconstructed images acquired with slice-by-slice mode; these are less obvious in images acquired with helical
mode.
Computed tomography is based on X-ray densitometry. The linear absorption in high kV x-ray beams is
Track B
mainly due to tissue density, or, more precisely, electron density. Therefore high electron density tissues, such as
bone, possess a higher linear absorption compared to low electron density tissue such as fluids or fat. The
attenuation data obtained from the different projections are re-calculated using a mathematical process (called
filtered back projection). The computer produces a matrix of the average relative X-ray absorptions in each voxel
(volume element) in the slice of tissue examined. These values are transformed into Hounsfield units (HU) or CT
1
numbers, normalised to voxel values containing water (HU of water = 0). Some examples of HU are listed below
(table 1).
Tissue type Standard value HU

Bone (compact substance) >250
Bone (spongious bone) 50–300
Coagulated blood 70–90
Thyroid gland 60–80
Liver 50–70
Whole blood 50–60
Advanced
Brain grey matter 37–41

Muscle 35–50
Kidney 20–40
Brain white matter 20–34
Plasma 25-29
Cerebrospinal fluid 5-10
Fat -80 to -100
Lung -950 to -550
Table 1. The Hounsfield Unit scale
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The HU value can be affected by physiological changes or pathological processes affecting a particular
tissue (e.g. oedema would lower the HU of brain and increase the HU of lung). On the basis of the HU the voxel is
represented on the monitor as a pixel of different shades of grey, white or black. The monitor usually displays 32-64
levels of grey; the window width (WW) and the window level (WL) are selected in order to better display the tissue of
2
interest. The WL is set at the mean HU of the region of interest. The window width should reflect the range of
tissues, which need to be discriminated on each side of the window level. For example when viewing the thorax one
would view the images selecting a lung window for pulmonary lesions and selecting a mediastinal window for
mediastinal lesions. An example of different windows is given in Figure 1.
Figure 1. CT of the tympanic bullae of a cat. A: Bone window (WW=1500 WL= 300) B: soft tissue window (WW=350 WL=40)
Most CT studies would include post-contrast images. The contrast used is iodinated contrast medium
injected intravenously as a bolus. Pressure injectors are useful for angiography studies and enable better control of
the contrast administration rate compared with manual injections. Post contrast images are acquired nearly
immediately after injection for the arterial phase of contrast distribution and several seconds later for the venous and
tissue phases: the exact timings are also dependent on patient size and contrast injection rate. After intravenous
injection the contrast is eliminated by glomerular filtration therefore CT can be used to visualise the renal collecting
system and ureters
CT images are easy to interpret as they are similar to radiographs. In CT, structures that cause little
attenuation of the x-ray beam (low density structures) appear dark and are described as hypoattenuating (e.g. lung).
Structures that cause strong attenuation of the x-ray beam (high density structures) appear white and are described
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as hyperattenuating (e.g. bone). Structures can also be described as air, fat, soft tissue or mineral density depending
on their HU.
Magnetic Resonance Imaging

The principles of magnetic resonance were firstly described in 1937 with the observation that the atomic
nuclei show their presence by absorbing or emitting radio waves when exposed to a sufficiently strong magnetic field.
It was not until 40 years later (1977) that the first human MRI was made. The nuclei of atoms (hydrogen) behave like
tiny, spinning magnets. When placed in a strong, static magnetic field these tiny magnets align with it. When hit with
a pulse of radio waves, the hydrogen nuclei absorb energy, become excited and change direction. The time it takes
them to return to their original state (relaxation time) can be measured. A coil (placed close to the body part of
interest) will receive the energy emitted by the nuclei when they return to their original state. The energy emitted and
the speed of return to equilibrium are dependent on the nature of the structure to which the nuclei belong. In MRI, the
physical and biochemical characteristic of a tissue affect the signal intensity of that tissue.
Furthermore the ability to distinguish between different types of tissues is enhanced by the combined use of
different imaging sequences. Common pulse sequences are T1 and T2 spin-echo sequences. Grossly in T1
weighted (w) images fluid appears black and in T2w images white (fat appears white in both, Figure 2). Other
common sequences are: FLAIR (Fluid-Attenuated Inversion Recovery) in which CSF- like fluid is black (the signal
from fluid is suppressed); STIR (Short TI Inversion Recovery) in which the bright signal from fat is suppressed while
the bright signal from fluid is retained; and GE (Gradient Echo) which allows for rapid scanning and is sensitive to
1
inhomogeneities of the field, such as those cause by ferromagnetic material (magnetic susceptibility artefacts). GE is
used in case of suspected haemorrhage.
140
Figure 2: MRI of a cat with hydrocephalus. The CSF in the ventricular system appears back (hypointense) in image A (T1
weighted) and white (hyperintense) in image B (T2 weighted). The fat within the spongious part of the frontal bone appears white
in both sequences.
When interpreting MRI it is important to understand that a number of factors influence the MRI signal, for
example a change in the composition of a certain fluid may result in loss of its signal intensity in T2 (e.g. otitis
interna). Gadolinium is the contrast used in MRI; it increases the visibility of inflammation, a tumor or growth, blood
vessels, lymph nodes and scarring tissue. When interpreting an MRI, structures are described according to their
intensity compared to a known structure in a particular sequence (e.g. this lesion appears hyperintense to the brain
cortex in T2 weighted images). With MRI a body part can be imaged in any plane with maximal resolution.
Two types of MRI scanner are used in veterinary clinical practice: the superconducting electromagnet and
the permanent magnet. Superconducting magnets produce high-field magnetism (1-3 Tezla). They produce excellent
quality images but are expensive with high running costs. The permanent magnets are opened at the side (C-
shaped), provide low to mid- magnetic field (0.25-0.7T) and are cheaper to buy and run. When working with MRI it is
important to implement specific safety guidelines: this is particularly true for superconducting magnets.
Clinical Applications
MRI is preferred to CT for visualisation of soft-tissue structures. It is the imaging modality of choice for brain
diseases with the added benefit of avoiding the streaking (beam-hardening) artefact produced in CT over the
brainstem and cerebellum by the radiodense temporal bone. A number of central nervous system diseases can be
diagnosed with MRI (table 2). Normal cortical bone is not well visualised on MRI because it is a tissue that contains a
limited amount of free hydrogen. The lack of signal from cortical bone makes it difficult to distinguish from air, hence
structures such as the tympanic bullae, nasal cavities and paranasal sinuses are inherently difficult to examine by
Track B
MRI. In case of nasal tumours and otitis media MRI enables better establishment of possible extension into the brain
3
and/or associated meningeal reaction.
Brain Spine
Neoplasia Inflammatory/infectious disease e.g. FIP
Inflammatory/infectious disease e.g. FIP Neoplasia e.g. lymphoma
Congenital anomalies Trauma e.g. spinal haemorrhage
Nutritional/metabolic disease Congenital anomalies e.g. spinal arachnoid cyst
Cerebrovascular accident e.g. secondary to hypertension Vascular e.g. ischemic myelopathy
Cranial nerves diseases Degenerative/ metabolic disease
Table 2. Example of diseases investigated with MRI
In case of spinal disease CT offers excellent bone detail and therefore is the modality of choice when looking
4
for fractures. In case of lesions of the intervertebral discs, spinal cord and nerve roots MRI is preferred. CT is often
used for orthopaedic disease; MRI has the advantage of offering better soft tissue and cartilage detail.
Air is certainly not rich in atoms; therefore the lung field is not examined well with MRI. CT is the modality of
choice for non-cardiac thoracic disease, when CT is not available the combined use of radiography and ultrasound is
usually able to establish a diagnosis. CT angiography may be used to detect pulmonary thromboembolism. CT is
very valuable to guide needle biopsies of any lesion that is not in contact with the thoracic wall and therefore cannot
be visualised via ultrasound.
A common use of CT in feline medicine is to establish tumour extent, for example in case of fibrosarcoma, in
order to plan surgical removal. Some examples of diseases diagnosed with CT are given in table 3.
141
Thorax Abdomen Mix
Lower airways disease Portosystemic shunt Skull and vertebral fractures
Pyothorax Neoplasia e.g. evaluation of extent Fibrosarcoma
Neoplasia e.g. met check Para-aortic abscess Nasal disease e.g. neoplasia
Trauma Diaphragmatic rupture Acromegaly (also with MRI)
Table 3 Example of diseases investigated with CT
Abdominal MRI is not routinely used in veterinary medicine. There are two imaging options for feline
abdominal disease: ultrasound or CT. Practically ultrasound is excellent in most of the cases, with regards to feline
medicine in particular it offers detailed visualisation of a number of abdominal structures (e.g. intestinal layers,
common bile duct, pancreatic duct, duodenal papilla, ileocecocolic junction etc.). Abdominal CT is of limited value
without the use of contrast. Compared to CT, ultrasound has the advantage of avoiding the need for deep sedation or
general anaesthesia. Ultrasound also enables rapid sampling of any lesion encountered under real time guidance;
the needle is advanced under direct visualisation and can be seen entering the region of interest. CT can be very
useful in case of complex vascular anomalies and when a lesion is extending into the lumbar or pelvic region.
Clinical signs/ findings MRI CT Ultrasound
Head tilt Excellent Good -
Seizures Excellent If MR not available -
Neck mass Good Excellent -radiation planning Good to poor
Pleural effusion - Excellent Excellent to good
Tachypnea - Excellent Good to poor
Diarrhea - Good Excellent
Azotemia - Good but needs GA Excellent
Table 4 Which imaging modality should I use: MRI, CT or ultrasound?
References
th
1. D’Anjou MA. Chapter 4: Principles of Computed Tomography and Magnetic Resonance Imaging. Thrall 6
Edition. Saunders 2012.
2. Tidwell AS, Jones JC. Advanced imaging concepts: a pictorial glossary of CT and MRI technology. Clin Tech
Small Animal Pract 14(2):65, 1999
3. Negrin A, Cherubini GB, Lamb C, et al. Clinical signs, magnetic resonance imaging findings and outcome in
77 cats with vestibular disease: a retrospective study. J Feline Med Surg 12(4):291, 2010
4. Da Costa RC, Samii VF. Advanced imaging of the spine in small animals. Vet Clin North am Small Anim
Pract 40(5):765, 2010
NOTES:
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Choosing & Using Radiology & Ultrasound Equipment

Introduction
The market is full of different radiography systems and ultrasound machines. There is a wide spectrum of
capabilities, portability and costs associated with these systems. In order to make a satisfactory choice it is important
to have some knowledge of the equipment specifications.
Radiology Equipment
It is not easy to determine which system is right for your practice. A number of factors should be taken into
consideration.
If your practice is seeing dogs and cats then the x-ray generator must be powerful enough to obtain good
quality images in large dogs. An x-ray generator should be of at least 200mA. High exposure factors (high mAs) are
needed to image large dogs. Low output machines need a long exposure time to obtain high mAs; therefore high
exposures obtained with a low output machine result in motion blur artefact. If running a feline only clinic, the power
of the x-ray generator is less of an issue as only low exposures are required.
Image resolution is of primary importance when imaging cats. Small patients require a higher resolution
system than large animals. Spatial resolution is the ability to detect a structure against its background (smallest
possible structure that can be detected). The line pair phantom measures resolution in terms of line pairs per
millimetre (lp/mm). This tool tests the ability to recognise two small structures close together as separate.
Conventional radiography has a very high spatial resolution (10-15 lp/mm), much higher than any veterinary digital
radiography systems. Therefore conventional radiography is excellent to see the small pulmonary structures or the
details of the musculoskeletal system of cats. When buying a digital system, the resolution specifications must be
checked. The suggested value to look for in a digital system is a resolution greater than 2.5 lp/mm after processing.
High quality digital systems have a resolution of 5 lp/mm. For digital images, the image resolution is also expressed
in pixels/mm. Contrast resolution is another very important factor to consider when judging image quality. In this
respect digital radiography is better than conventional radiography as under- and over-exposure can be corrected.
Digital images have greater latitude (wide dynamic range) than conventional radiographs. When buying a new digital
system the vendors will tend to show images of a large dog abdomen or thorax, but to assess the quality of the
images check if you are satisfied with radiographs of cats.
Most digital radiography systems can be used with the existing x-ray machine. If you are keeping your old x-
ray generator, before buying a digital system the x-ray generator must be checked to see if it can be used for digital
radiography. Some problems that would not affect the quality of conventional radiography may affect digital
radiography (e.g. line voltage fluctuation).
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Before buying a new system do your research. Asking around is good but you should consider that the
person who has bought the system is not objective; generally the person who has bought the system will tell you it
has been a good choice and the system works perfectly. Asking other veterinarians employed at the clinic, the
nurses or the radiographers is a better way to find out if the system performance is satisfactory. Keep an objective
judgement towards the product, regardless of your opinion on the salesman. A low buying price may be appealing
but it is important to consider the support the company offers. The service support is mostly down to the individual
service engineer; the best way to find out if it is of good quality and efficient is by asking other consumers.
Avoid buying products that are towards the end of their technical life, as they will not be supported. By getting
products from undercapitalised companies or from companies with a different primary focus you run the risk of
ending up with an unsupported product.
Digital radiography is divided into computed radiography (CR) and direct radiography (DR). Computed
radiography uses cassettes containing a screen where the image is stored after exposure. The CR cassette is then
digitally read and processed. The time to process a CR image is a bit less (60-90 sec) than that taken to develop a
conventional radiograph. There are a variety of DR systems. To simplify they all generally work with detectors that
1
are directly wired to the interface and the images can be viewed within few seconds of exposure.
Digital radiographs are viewed at workstations. The workstation is basically a computer provided with Digital
Imaging and Communication in Medicine (DICOM) viewing software and monitor. Interpretation of radiographs
cannot be done on any screen. Monitor quality is based on 3 parameters: resolution, luminance and contrast ratio.
When buying a monitor one should not buy only spatial resolution (megapixels); the brightness of the monitor
(luminance) and the difference between brightest colour and darkest colour (contrast ratio) are also extremely
important. Quality requirements for monitors used to interpret CT and MRI are not as high as for radiography, while
human mammography requires the highest standards. Depending on the target structure assessed comparison
between different monitors performance may result in equal display quality or difference in display quality. The
2
average laptop screen (screen brightness 200cd/m ) is considered suboptimal for interpretation of feline radiographs.
143
Assuming that feline radiography is comparable to mammography, the monitor requirement to interpret feline
2 2
radiography would be of a luminance of at least 250 cd/m , and of 450 cd/m for optimal contrast. The higher the
luminance ratio of the display, the larger the luminance resolution (bit-depth) should be. A minimum of 8-bit depth is
2
required but 9-bit or higher is recommended for feline radiographs.
Digital images can be attached to the patient file and can be emailed for a second opinion. When emailing
the images for a second opinion they should be sent in a DICOM format, which for one radiograph is about 12MB.
Converting the images into a smaller file format (e.g. jpeg) before sending them compresses the image data and
some of the image information is lost.
PACS (Picture Archive and Communication System) is the infrastructure that connects digital radiography
systems (and possibly other modalities system), workstations, the image archive and the electronic medical record. A
PACS is useful in large practices using other modalities (e.g. ultrasound, CT) and more than 1 workstation. One
should ask about the capabilities of the PACS with regards to DICOM compliance, image exporting possibilities and
remote access.
Your personnel (vets, nurses, radiographers) may perceive digital radiographs as free of charge. It is true
that the running cost may be lower than with conventional radiography, but a big expense has been made to
purchase the system. Furthermore digital systems have a short life, lasting generally between 5 and 7 years,
therefore the personnel must be made aware of the importance of charging digital radiographs.
Ultrasound
First of all decide whether you need a portable or a console unit. New console units generally offer a very
good image quality and are more expensive than small portable units. Some refurbished, second hand console units
(mostly from the human medical field) can make a very good deal as, for the price you pay, the image quality is
generally good. However, when buying pre-owned, avoid systems that are at the end of their technical life. Also
consider that console machines may be fairly bulky; you need space in the practice to park and use the machine.
Some years ago there was a big gap in image quality between the portable ultrasound unit and the console units.
Nowadays it is possible to find very good quality portable machines, and for a competitive price. The market is full of
different models of portable machines, some as small as a large mobile phone, with a wide range of prices. The
quality and price difference between one machine and another one can be massive; generally you pay for what you
get. A cheap new portable unit may seem a very good deal but it is not if the images produced are substandard and
non-interpretable. Furthermore, only few portable machines on the market are good for use in both echocardiography
and abdominal ultrasound. To find your way in this wide market, it is useful to ask the opinion and advice of a
radiologist or a colleague who has good knowledge of the ultrasound products.
Before purchasing an ultrasound machine you can ask to test it at your practice. Make sure that somebody
with good ultrasound experience (you or one of your colleagues) is available on that day to test the machine. The
machine should be tested on a variety of patients (cats versus large fat dogs), particularly if it is needed for use in
dogs and cats.
The manufacturer should set up the machine appropriately. The seller should pre-set the machine so that in
the menu you can choose from a range of protocols. Protocols should include: cardiac cat, abdominal cat and
Track B
superficial structures (e.g. thyroid). If you are using the ultrasound also for dogs; dogs’ protocols should be added.
Frame rate, image width, starting point image depth, reject level, image persistence, power setting and measurement
packages are pre-determined and tailored for each protocol. Having correct pre-set protocols is essential for efficient
ultrasound; the previously listed parameters are generally kept as they are in every patient; only the focus, depth and
gain are adjusted during the exam.
Every manufacturer would be able to provide you with the list of probes available for a specific machine. For
feline ultrasound you would need at least a sector probe 5-7.5 MHz and a linear probe 8-11 MHz. The sector probe is
used for echocardiography and to visualise the deepest parts of the abdomen. The linear probe is used for
abdominal and cervical ultrasound; it offers high resolution and is necessary for detailed examination of the organs
(e.g. intestinal layers). A third probe, curvilinear, may be purchased as a better alternative to the sector probe for the
deepest parts of the abdomen.
The ultrasound machine needs to be serviced approximately once a year. Purchase considerations
regarding service and support from the manufacturer/retailer are as discussed for radiography. Keeping the machine
in a dirt free environment certainly prolongs the life of the equipment. Considering that keeping the environment hair
free is impossible one should at least try one’s best to avoid excessive exposure to it (e.g. plastic cover over the
machine when not in use, use the machine in a clean room). The probes should be cleaned after every use with a
damp cloth. To preserve the probes is suggested not using spirit on the patient.
The ultrasound room must be a quiet room where the light can be totally shielded. Having a room dedicated
to ultrasound is the ideal situation to work efficiently; when this is not possible an unoccupied room should be
selected for this purpose. In any case it is important to make colleagues aware of the fact that access to the room
should be limited during the ultrasound examination, particularly if working on a conscious or lightly sedated patient.
144
Using Radiography and Ultrasound
A radiographic study should include 2 views in most of the cases, occasionally a single view may be
considered satisfactory. For example, in case of suspected cardiac failure if pulmonary edema is evident in the first
radiograph there is no need to take the second view and cause further stress to the patient. When setting up to take
radiographs decide whether an appropriate chemical restraint is necessary. For example when looking for skull
fractures correct positioning is essential, this is unlikely to be achieved in a conscious cat. When holding a patient for
a conscious radiograph it is important to make sure the local radiation regulations are respected. Adopt a case-by-
case approach when deciding the exposure factors and technique (e.g. use of a grid) as not all cats are the same.
There is surely less variation in size amongst cats when compared to dogs but a fat cat of 8 kg is different than a slim
3 kg cat.
Abdominal ultrasound is generally well tolerated by feline patients however anxious cats may need sedation.
Scanning after endoscopy or after barium contrast study should be avoided; in the first instance the gastrointestinal
tract is full of air and in the second barium causes reverberation artefacts of the ultrasound beam. When possible
food should be withheld from the evening preceding the abdominal ultrasound; this is essential for optimal
assessment of the cranial abdomen and G-I tract. When performing an ultrasound it is important to complete the
abdominal examination and produce a final written ultrasound report.
Ultrasound and radiography are complementary imaging techniques. The decision of which technique to use
is taken on a case-by-case basis. However some general guidelines can be made regarding selection of the most
appropriate technique. In general, radiography is used in case of suspicion of nasal, respiratory, skeletal and ear
disease; whereas ultrasound is used in case of suspected pleural, mediastinal, cardiac, and abdominal disease. In
case of urinary or gastrointestinal disease, ultrasound alone, radiography alone or a combination of the two
techniques is undertaken. Ultrasound is used for obtaining biopsies or fluid sample from an abnormality discovered
on imaging (or on blood analysis). Ultrasound is used to guide the needle to the appropriate area; the patient should
not move while performing the biopsy therefore sedation is generally necessary. If the lesion is very superficial and
the patient very weak and subdued, sedation may not be required.
References
1. Drost WM. Transitioning to digital radiography. J Vet Emerg Crit Care 2011; 21(2): 137-143
2. Ludewig E, Boeltzig C, Gäbler K et al. Display quality of different monitors in feline digital radiography. Vet
Radiol & Ultrasound 2011; 52(1): 1-9
NOTES:
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NOTES:
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146
Feline Lymphoma
Introduction
Lymphoma is the most common hematopoietic tumor in cats, and diagnostic techniques, treatment options,
and expected prognosis had been unchanged for decades. New information has recently emerged regarding
different morphological variants of feline lymphoma, diagnostic options, treatments and prognosis. For better or
worse, we are dealing with a new generation of cats with lymphoma and although some questions have been
answered, new challenges have been identified as well.
Clinical Presentation, Diagnosis, and Staging

As more studies have examined our ability to diagnose lymphoma in cats using cytology, histopathology,
immunohistochemistry, and/or PCR testing for antigen receptor rearrangement, conflicting reports have arisen
regarding the frequency of small and large cell lymphoma in cats. When lymphoma cases diagnosed using cytology
1
or histopathology are included, large cell lymphoma is the most common form diagnosed. When only cases
diagnosed via histopathology are included, results regarding the relative frequency of large and small cell lymphoma
are mixed. A large study of 602 samples that classified lymphomas according to the National Cancer Institute
2
working formulation also found that large cell lymphomas were more common; however, a more recent study that
classified samples according to the World Health Organization criteria found that mucosal T-cell lymphoma is the
3
most common form. This form of feline lymphoma is associated with indolent clinical behavior and prolonged
survival time and consists of small to intermediate-sized lymphoma cells, which is consistent with current terminology
that refers to this type of lymphoma as small cell or low-grade lymphoma.
Large Cell Lymphoma

This form of lymphoma has been recognized the longest, and it is the subject of the majority of research into
feline lymphoma. Unfortunately we have been unable to break through the “locked cat door” regarding response
rate, remission duration, and survival times that can be achieved with conventional chemotherapy, and new
treatment strategies are needed. Large cell lymphoma can affect any area of the body, but the most common
locations are the gastrointestinal tract, non-gastrointestinal tract abdominal locations such as the spleen or kidneys,
4
nasal cavity, CNS, peripheral lymph nodes with or without liver and spleen involvement, and the mediastinum. Cats
with large cell lymphoma typically exhibit clinical signs referable to the anatomic location involved, and the physical
examination abnormalities are related to the anatomic site as well.
Diagnosis of large cell lymphoma is often made during the work-up for an ill cat, and the presence of a
palpable mass, facial deformity, pleural effusion, and positive FeLV status will raise the index of suspicion for large
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cell lymphoma. Because the neoplastic cells are large lymphoblasts that exfoliate well, fine needle aspiration and
cytology is often sufficient to make the diagnosis. If cytology is unrewarding, then biopsy can be pursued to obtain a
definitive diagnosis.
Most of the recommended staging tests for large cell lymphoma are typically performed during the diagnostic
work-up that resulted in the diagnosis of lymphoma; however, it is typically recommended that cats diagnosed with
large cell lymphoma have a complete blood count, chemistry panel, urinalysis, FIV/FeLV testing, chest radiographs,
and abdominal ultrasound performed. Additional staging tests (such as CT scan or regional lymph node aspirate)
may be recommended depending on the anatomic site involved. When I am presented with a cat with large cell
lymphoma, if any of the above tests have not already been performed I will finish the staging process prior to
initiating treatment.
Small Cell Lymphoma

This form of lymphoma has been recognized for over 10 years as a morphologically distinct variant from
large cell lymphoma. The clinical presentation and biological behavior of this form of lymphoma is also quite different
from that of large cell lymphoma, as is the recommended treatment. Small cell lymphoma almost always affects the
5-9
gastrointestinal tract with or without abdominal lymph node and other abdominal organ involvement. Cats with
small cell lymphoma tend to present with a longer history and lower severity of clinical signs compared to cats with
large cell lymphoma.
The neoplastic cells closely resemble normal small lymphocytes, so it is very difficult to diagnose small cell
lymphoma on cytology alone. Even with full-thickness biopsy samples, making a definitive diagnosis of small cell
lymphoma (versus inflammatory bowel disease/IBD) in the cat can be challenging. Additional diagnostic tests such
as flow cytometry, immunohistochemistry (IHC), and PCR for antigen receptor rearrangement (PARR) can be used
to help support or rule out small cell lymphoma; however, none of these tests is without flaws. Flow cytometry and
IHC will both identify the type of lymphocytes in question (B or T cells). Unfortunately, both small cell lymphoma and
147
inflammatory bowel disease are associated with T lymphocytes, test alone is unlikely to distinguish between the two
10,11
diseases except in the relatively uncommon situation of small cell B cell lymphoma. PARR will also identify the
lymphocyte population but is primarily a test for clonality: monoclonal lymphocyte populations are more likely to be
12
neoplastic compared to polyclonal populations, which are more likely to be reactive. The sensitivity (78% in T cell
lymphoma and 50% in B cell lymphoma) of PARR testing in distinguishing small cell lymphoma from inflammatory
bowel disease is not high enough to allow PARR to be a stand-alone test to determine if a cat has small cell
10.13
lymphoma or IBD. Current recommendations for distinguishing small cell lymphoma from IBD include a
12
combination of histopathology, IHC, and PARR. That paper reported that the specificity of histopathology for
distinguishing small cell lymphoma from IBD is 99.9%, meaning that it is very unlikely that a pathologist would
diagnose a cat with small cell lymphoma when the actual diagnosis is IBD. On the other hand, the specificity is 72%.
As IHC and PARR are added to the diagnostic regime, the specificity increases to 78% then 83%, while the
sensitivity remains unchanged. This information underscores the importance of incorporating all clinical and
diagnostic information instead of relying on one specific test when attempting to determine if a cat has small cell
lymphoma or IBD.
The recommended staging tests for cats with small cell and large cell lymphoma are similar with the
exception of one additional test that is recommended for cats with small cell lymphoma. Cats with small cell
lymphoma are at risk for cobalamin deficiency, which can exacerbate their clinical signs. One study of cats with
small cell lymphoma found that 78% of them were cobalamin deficient, so measuring serum cobalamin and
6
supplementing as indicated is recommended in these patients. Small cell lymphoma is unlikely to affect intrathoracic
structures except for the sternal lymph node. An enlarged sternal lymph node is unlikely to change the treatment
plan, but monitoring how the lymph node changes (or not) with treatment can be a helpful addition to repeat
abdominal imaging when assessing response to treatment.
Other Cell Types

Intermediate cell, large granular lymphocyte, Hodgkins-like, and T cell rich B cell lymphoma have all been
described in cats. No studies specifically examine the diagnostic procedures, treatment, and expected outcome for
cats with intermediate cell lymphoma. It appears that their biological behavior can be varied and they can mimic the
clinical picture of large or small cell lymphoma, which makes it difficult to decide upon a recommended course of
treatment. At the author’s hospital, if the clinical behavior of a cat with intermediate cell lymphoma is similar to large
cell lymphoma, then chemotherapy for large cell lymphoma is recommended, and vice versa. All of these variants are
uncommonly reported so it is difficult to make generalizations regarding recommended treatment protocols or
prognosis for them.
First Line Treatment

Large Cell Lymphoma
Combination chemotherapy with COP or CHOP protocols is considered the standard of care for the
treatment of large cell lymphoma in cats. A different session will focus on the details regarding different variations on
those protocols. One thing to keep in mind when treating cats with large cell lymphoma, particularly gastrointestinal
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large cell lymphoma, is that the clinical signs of progressive lymphoma (decreased appetite, vomiting, weight loss)
are very similar to common chemotherapy side effects (decreased appetite, vomiting, weight loss). That can make it
challenging to determine if a cat being treated for large cell lymphoma and who is acting ill is doing so because of
tumor progression, poor tolerance to chemotherapy, or both. One potential solution to this quandary is to alter
chemotherapy protocols to include other drugs that are less likely to cause these side effects.
The author has recently completed and published a prospective randomized clinical trial comparing the
15
efficacy and tolerance of vinblastine versus vincristine for feline lymphoma. Briefly, 40 cats with treatment-naïve
large cell lymphoma or progressive small cell lymphoma were randomized to receive a COP based protocol that
contained either vincristine or vinblastine. Owners were blinded to their cat’s study group to minimize bias in their
reporting of clinical signs. Cats that experienced clinically significant gastrointestinal toxicity (end points established
a priori) could be crossed over to the other treatment group in an effort to maintain dose intensity if one of the two
drugs was poorly tolerated. Response rate, progression free survival, lymphoma specific survival, and the number of
cats in each group that crossed over to the other group due to gastrointestinal toxicity were compared between the
two groups. Response rate and outcome was very similar between the two groups. The number of cats that
switched from vincristine to vinblastine due to gastrointestinal toxicity was significantly higher compared to the
number of cats that switched from vinblastine to vincristine due to gastrointestinal toxicity. Neutropenia was more
common in the vinblastine group, but the number of dose reductions due to neutropenia was not significantly different
between the two groups.
Small Cell Lymphoma

Multiple reports have confirmed the efficacy of prednisone/prednisolone and chlorambucil for cats with small
cell lymphoma (Table 1). These protocols are typically well tolerated. Reported toxicities include mild to moderate
gastrointestinal signs and myelosuppression, but the benefits of treatment outweigh the risks in the majority of
148
patients with small cell lymphoma, particularly in the absence of co-morbidities such as chronic kidney disease or
diabetes mellitus.
Table 1. Published chemotherapy protocols, response rates, and outcome for small cell lymphoma. *If reference
provided outcome information in days, the value was converted to months for this table.
Protocol Response Outcome (months)* Reference

Rate
Prednisolone 10 mg PO q24h 69% CR CR duration 16 9
2
Chlorambucil 15 mg/m PO daily for 4 Survival 17
days every 3 weeks
Prednisone 5-10 mg PO q12-24h 56% CR CR duration 29.4 4
Chlorambucil 2 mg PO q48-72 hours 39% PR PR duration 14
Survival 23
Prednisolone 3 mg/kg PO q24h until 76% CR CR 18.9 6
CR, then 1-2 mg/kg q24h Survival 14.9
2
Chlorambucil 15 mg/m PO q24h for 4
days every 3 weeks
Prednisone or prednisolone varied 96% clinical Clinical remission duration 25.8 8
doses for 1 week, then tapered to 1 remission Survival not reported
mg/kg PO q48h
2
Chlorambucil 20 mg/m PO every 2
weeks
Rescue Therapies
Large Cell Lymphoma
Rescue chemotherapy options for large cell lymphoma will be covered in another session. Radiation therapy
16
to the abdominal cavity has been reported as a rescue therapy in 11 cats with intestinal lymphoma. Cats with small
and large cell lymphoma were included in that retrospective study. Radiation therapy was delivered in 2 daily
fractions of 4 Gy in most cats. One of the cats died shortly afterwards related to extensive hepatic infiltration of
lymphoma, and one cat experienced a decreased appetite for a few days. Otherwise the treatment was well
tolerated. The 10 cats that survived after treatment responded to therapy and had a median survival time after
treatment of 214 days. There were too few cats to compare outcome according to lymphoma cell type, and more
studies are needed in cats with both large and small cell lymphoma to determine how beneficial it would be to include
radiation therapy more routinely in the treatment of cats with intestinal lymphoma. Radiation therapy is more likely to
be used in cats with nasal or mediastinal lymphoma as either first line or rescue therapy.
Track B
Small Cell Lymphoma
Although most cats with small cell lymphoma respond well to treatment, not all of them do. In addition, some
cats may eventually relapse and be resistant to chlorambucil. The primary choices for rescue chemotherapy in cats
with small cell lymphoma are other alkylating agents: cyclophosphamide and lomustine. Two papers describing
treatment of small cell lymphoma with prednisone/prednisolone and chlorambucil comment on observed responses
8,9
to rescue treatment with cyclophosphamide. One reports that all 7 of 7 cats responded to cyclophosphamide
8
rescue treatment. Three of those cats eventually died of causes unrelated to lymphoma, and another 3 were lost to
follow up, so the duration of response to rescue is difficult to interpret. The second study does not describe objective
7
outcome parameters but states that “rescue extended the life of some of the cats.” When doxorubicin was examined
in the rescue setting for cats with lymphoma, responses were noted only in cats with small or intermediate cell
17
lymphoma. Similarly, cats with small cell lymphoma were reported to have longer response duration to rescue
18
therapy with lomustine compared to cats with large cell lymphoma.
Body Weight and Body Condition Score

The prognostic impact of lower body weight in feline lymphoma has been well documented, with cats that
15,16,19
have a lower body weight experiencing shorter survival times. A prospective study examining the effect of body
condition score (BCS) as well as weight on survival in cats with cancer found that cats with a BCS less than 5 had a
significantly shorter survival time for all cats as well as specifically for cats with lymphoma (3.3 versus 16.9 months, p
20
= 0.001). Remission status was also significantly correlated with BCS, as cats in remission had a mean BCS of 5.2
+/- 1.7 compared to a mean BCS of 2.8 +/- 1.9 for cats not in remission (p = 0.0008).
It is plausible that cats that weigh less and have a poorer body condition score will have more advanced
disease and be less responsive to and tolerant of cancer treatment. The next question to ask, then, is can weight
changes over time be used as a surrogate marker for response? It is likely that cats that are not responding to or
tolerating treatment will continue to lose weight, while patients that are responding to and tolerating treatment well
149
may gain weight. A recent study evaluated the impact of weight changes over time on survival time of cats with
21
lymphoma. Cats with large and small cell lymphoma were included, and weight measurements at baseline and 1, 2,
3, and 6 months after starting treatment were recorded from the medical records. Interestingly, this study found that
baseline weight was not predictive of survival. Changes in weight at the time points recorded did not correlate with
survival for cats with small cell lymphoma; however, changes in weight at the 1 month time point for cats with large
cell lymphoma did. Specifically, cats that lost > 5% of their body weight compared to baseline at the 1 month time
point had a significantly shorter survival time compared to cats with stable or increased weight. A similar trend was
found at the 2 month time point, but the difference was not statistically significant.
Ongoing Challenges
Advances have been made in the diagnosis and classification of feline lymphoma and associating lymphoma
type with treatment recommendations and outcome. In addition, investigation of different treatment strategies, such
as radiation therapy and different chemotherapy protocols (vinblastine instead of vincristine), have provided some
alternatives to standard treatment for these patients. However, several significant challenges for the successful
treatment of cats with lymphoma, particularly large cell lymphoma, remain.
As more studies have focused on specifically including cats with either small or large cell lymphoma, the
distinction in clinical behavior and prognosis between these two forms of lymphoma has become more obvious. In
general, the reported outcome for cats with large cell lymphoma appears to be less promising than it was 15 years
ago; however, the current numbers are likely a more accurate assessment because the positive effect of including
cats with small cell lymphoma on survival times has been removed. The next challenge then is to investigate new
treatment strategies to improve the outcome of cats with large cell lymphoma and to increase our ability to identify
cats that are more and less likely to respond to treatment. Effective supportive care and accurately determining
response to treatment remain challenges, and the recent studies that suggest that body weight and/or body condition
score can be used as surrogate markers for response underscore the importance of this aspect of feline lymphoma
treatment.
References
1. Russell KJ, Beatty JA, Dhand N, et al.: Feline low-grade alimentary lymphoma, how common is it? J Feline
Med Surg 14(12):910-912, 2012.
2. Valli VE, Jacobs RM, Norris A et al: The histologic classification of 602 cases of feline lymphoproliferative
disease using the National Cancer Institute working formulation. J Vet Diagn Invest 12:395, 2000.
3. Moore PF, Rodriguez-Bertos A, Kass PH. Feline gastrointestinal lymphoma: mucosal architecture,
immunophenotype, and molecular clonality. Vet Pathol 49:658, 2012.
4. Louwerens M, London CA, Pederson NC, et al: Feline lymphoma in the post-feline leukemia virus era. J Vet
Intern Med 19:329, 2005.
5. Carreras JK, Goldschmidt M, Lamb M, et al.: Feline epitheliotropic intestinal malignant lymphomas: 10 cases
(1997-2000), J Vet Intern Med 17:326-331, 2003.
6. Kiselow MA, Rassnick KM, McDonough SP, et al: Outcome of cats with low-grade lymphocytic lymphoma:
Track B
41 cases (1995-2005). J Am Vet Med Assoc 232:405, 2008.

7. Lingard AE, Briscoe K, Beatty JA et al.: Low-grade alimentary lymphoma: clinicopathological findings and
response to treatment in 17 cases, J Feline Med Surg 11:692, 2009.
8. Stein TJ, Pellin M, Steinberg H, et al.: Treatment of feline gastrointestinal small cell lymphoma with
chlorambucil and glucocorticoids, J Am Anim Hosp Assoc 246:413, 2010.
9. Fondacaro JV, Richter KP, Carpenter JL.: Feline gastrointestinal lymphoma: 67 cases (1988-1996), Eur J
Comp Gastroenterol 4:5, 1999.
10. Moore PF, Rodriguez-Bertos A, Kass PH: Feline gastrointestinal lymphoma: mucosal architecture,
immunophenotype, and molecular clonality, Vet Pathol 49:658, 2012.
11. Carreras JK, Goldschmidt M, Lamb M, et al.: Feline epitheliotropic intestinal malignant lymphomas: 10 cases
(1997-2000), J Vet Intern Med 17:326, 2003.
12. Avery AC: Molecular diagnostics of hematologic malignancies in small animals, Vet Clin Small Anim 42:97-
110, 2012.
13. Moore PF, Woo JC, Vernau W, et al.: Characterization of feline T cell receptor gamma (TCRG) variable
region genes for the molecular diagnosis of feline intestinal T cell lymphoma, Vet Immunol Immunopathol
106:167, 2005.
14. Kiupel M, Smedley RC, Pfent C, et al: Diagnostic algorithm to differentiate lymphoma from inflammation in
feline small intestinal biopsy samples. Vet Path 48:212, 2011.
15. Krick EL, Cohen RC, Gregor TP, Sorenmo KU. Prospective clinical trial to compare vincristine and
vinblastine in a COP-based protocol for lymphoma in cats. J Vet Intern Med 27:134, 2013.
16. Parshley DL, LaRue SM, Kitchell B, et al: Abdominal irradiation as a rescue therapy for feline gastrointestinal
lymphoma: a retrospective study of 11 cats (2001-2008). J Feline Med Surg 13:63, 2011.
150
17. Oberthaler KT, Mauldin E, McManus PM, et al.: Rescue therapy with doxorubicin-based chemotherapy for
relapsing or refractory lymphoma: a retrospective study of 23 cases, J Feline Med Surg 11:259, 2009.
18. Dutelle AL, Bulman-Fleming JC, Lewis CA, et al.: Evaluation of lomustine as a rescue agent for cats with
resistant lymphoma, J Feline Med Surg 10:694, 2012.
19. Hadden AG, Cotter SM, Rand W, et al: Efficacy and toxicosis of VELCALP-C treatment of lymphoma in cats.
J Vet Intern Med 22:153, 2008.
20. Baez JL, Michel KE, Sorenmo K, et al.: A prospective investigation of the prevalence and prognostic
significance of weight loss and changes in body condition in feline cancer patients, J Feline Med Surg 9:411,
2007.
21. Krick EL, Moore RH, Cohen RB, et al.: Prognostic significance of weight changes during treatment of feline
lymphoma, J Feline Med Surg 13:976, 2011.
NOTES:
Track B
151
NOTES:
Track B
152
Neoplastic Effusions
Introduction
Neoplastic effusions can represent an oncologic emergency depending on their severity and rate of
progression. The determination of whether an effusion is neoplastic or due to another cause can be challenging.
The prognosis for a cat with a neoplastic effusion will depend on the type of cancer that is causing the effusion and
the cat’s response to treatment. We will review diagnostic options for and the most common causes of neoplastic
effusions in cats.
Signalment and History
Cancer is most common in older cats. Patients with neoplastic effusions may have no significant prior health
history, or they may have a known diagnosis of cancer. Depending on the location of the effusion they may present
with dyspnea, tachypnea, lethargy, weakness, decreased appetite, or collapse.
Physical exam findings will also depend on the location and volume of the effusion. The severity of the
clinical signs and physical examination abnormalities will also depend on the chronicity of the effusion—a cat who
has had effusion for weeks to months has had time to compensate and will likely be less affected by a large volume
of effusion compared to a cat that developed effusion more quickly without time to compensate. Physical
examination abnormalities associated with pleural space disease include decreased lung sounds, muffled heart
sounds, and decreased chest compliance as well as tachypnea and dyspnea. Pericardial effusion, though rare, is
suspected in cats with normal lung sounds but muffled heart sounds, particularly if coupled with pulse abnormalities
or deficits. Physical examination abnormalities associated with peritoneal effusion include abdominal distension, and
possibly pain on abdominal palpation depending on the cause of the effusion. Patients with hemoperitoneum are
likely to present in hypovolemic shock.
Additional physical examination abnormalities that may be noted in cats with neoplastic effusions include
poor skin turgor, pale and/or tacky mucus membranes, decreased capillary refill time, lethargy, weakness, muscle
wasting, and abdominal mass or masses.
Diagnostic Tests
Imaging
The extent of imaging initially depends on the stability of a patient. Abdominal and thoracic imaging may be
possible in a stable patient, while only thoracic imaging to identify effusion may be possible initially in an unstable
patient.
Track B
Thoracic radiographs are often the first imaging test performed in cat suspected to have pleural effusion (or
who present with dyspnea). If these radiographs reveal the presence of pleural effusion, then thoracic ultrasound
may be performed to better visualize any masses or lymphadenopathy noted on radiographs and to identify an area
for thoracocentesis that is likely to yield diagnostic and therapeutic benefit. Because the fluid will make accurate
interpretation of the radiographs difficult, repeating the radiographs after thoracocentesis can allow for more detailed
global evaluation of the intra-thoracic structures. If the radiographs are suspicious for pericardial effusion, then an
echocardiogram would be recommended to confirm the effusion and direct pericardiocentesis.
The presence of effusion makes it difficult to accurately interpret abdominal radiographs as well, so
abdominal ultrasound is recommended in patients suspected to have peritoneal effusion in order to identify
abnormalities in the abdominal cavity as well as confirm the presence of effusion and guide diagnostic
abdominocentesis.
Laboratory Tests
Results from complete blood count and chemistry panel evaluation and FIV/FeLV testing may help to raise or
lower the index of suspicion for a neoplastic effusion. For example, a positive FeLV test or the presence of
peripheral blood lymphoblasts will increase the suspicion for lymphoproliferative disease, while left-shifted
neutrophilia will increase the suspicion for an infectious etiology.
Once a sample of the effusion is obtained, fluid analysis and cytological evaluation will likely yield a
diagnosis if large cell lymphoma is the cause. It is extremely rare for small cell lymphoma to cause a neoplastic
effusion; however, some cats with lymphoma in the thoracic cavity will have chylothorax, which can make it difficult to
definitely diagnose lymphoma just based on fluid analysis and cytology. In one study evaluating causes of pleural
effusion in 82 cats, mediastinal lymphoma was the diagnosis in 17% of cats, while the underlying disease was
1
pulmonary neoplasia in 6% of cats. Pericardial lymphoma has been recently described in seven cats, all of whom
2
presented with pleural and/or pericardial effusion and a thickened pericardium. Six of the seven cats were FeLV
153
positive. An older case report describes an eighth cat with pericardial lymphoma that also presented with pleural and
3
pericardial effusion.
If the source of the neoplastic effusion is not lymphoma (or another round cell tumor such as mast cell
tumor), then obtaining a definitive diagnosis can be more challenging. Additional differential diagnoses for cats with
neoplastic effusions include carcinomatosis and mesothelioma. Distinguishing between these two differentials can
4
be challenging, as normal mesothelial cells will proliferate and exhibit dystrophic changes when exposed to effusion.
Therefore, it is often not possible to determine if any abnormal cells seen are reactive or neoplastic mesothelial cells
based on cytological evaluation of fluid alone. If fluid analysis does not yield a diagnosis and masses are visualized
with imaging, then the next step is to sample those lesions via biopsy or fine needle aspiration, depending on the
location of the masses, the index of suspicion for lymphoma versus another disease, and the status of the patient.
Even if biopsy samples are obtained, the histopathological variants of mesothelioma can also make a
definitive diagnosis challenging. A recent study evaluating several different immunohistochemical (IHC) markers in
feline mesothelioma samples showed that regardless of mesothelioma type (epithelial, sarcomatous, or biphasic), all
5
10 samples stained positively for vimentin and cytokeratin AE1/3. Staining for both markers is useful for
differentiating mesothelioma from carcinomas (typically vimentin negative) and sarcomas (typically cytokeratin
negative). A comparison in staining of mesothelioma and reactive mesothelial cell proliferation was not made in this
study, and it is unlikely that the IHC described would distinguish between those two conditions.
Prior to pursuing thoracic surgery in a cat suspected to have neoplastic effusion, a CT scan can be helpful to
better delineate the presence of pleural masses and to evaluate the lungs for the presence of a primary mass and/or
6
metastatic lesions depending on the amount of effusion present at the time of the CT scan. Thoracoscopy has
recently been offered as an alternative to open chest surgery and has been shown to provide excellent visualization
7
of the pleura and biopsy samples of adequate quality for diagnostic histopathological evaluation. Three cats were
included in that study—one cat with carcinomatosis died after the procedure, while the other 2 cats were diagnosed
with non-neoplastic conditions and did not experience significant complications following the procedure.
Given the invasiveness of thoracic surgery, even with thoracoscopy, the increased anesthetic risk for
patients with pulmonary or pleural space disease, and the poor prognosis associated with mesothelioma and
carcinomatosis, some owners may decline surgery and biopsy procedures. In that case it would helpful if it was
possible to test the effusion in a different way to at least find out if it is a neoplastic effusion or not. One study
compared fibronectin concentrations in neoplastic and non-neoplastic effusions in 84 cats and found that fibronectin
8
concentrations were significantly higher in neoplastic pleural effusion versus non-neoplastic pleural effusion. When
a cut-off value of 31.5% for fibronectin was used, the sensitivity was 100% and the specificity was 76%, indicating
that if the fibronectin concentration in a sample of pleural effusion from a cat is below 31.5%, neoplasia can be ruled
out. A higher % of fibronectin in an effusion could mean that the effusion is due to neoplasia or a different cause.
Treatment and Prognosis

Lymphoma
Two of the 8 cats with pericardial lymphoma described in the literature received CHOP-based chemotherapy
2,3
protocols, and their survival times were reported to be greater than 6 months and greater than 750 days.
Track B
Treatment with COP or CHOP-based protocols is considered standard treatment for cats with mediastinal
lymphoma. Outcome information is variable, with young, FeLV positive cats having expected survival times of 2 to 3
9-
months with treatment, while older, FeLV negative cats are expected to have a more durable response to treatment.
12
Radiation therapy can be used in addition to chemotherapy or as a sole treatment modality and can be used
as a first line or rescue treatment. The response rate of feline mediastinal lymphoma to radiation therapy is not well-
reported. One study evaluating the effectiveness of radiation therapy with and without chemotherapy for cats with
lymphoma included one cat with mediastinal lymphoma who received two 8Gy fractions of radiation therapy, one
13
dose of vincristine, and oral prednisione. This cat had a complete response to treatment that lasted for over 2 and
½ years.
Mesothelioma and Carcinomatosis

No definitive therapy is currently available for cats with mesothelioma. All treatments are aimed at palliating
the clinical signs associated with the disease. Individual reports of using chemotherapy to decrease the amount of
effusion in order to palliate patients have been published, but no studies examining treatment for feline mesothelioma
14,15
have been published. One cat with peritoneal mesothelioma treated with intracavitary carboplatin and injectable
14
piroxicam died of progressive disease after 6 months, while another cat with suspected pleural mesothelioma
15
treated with intracavitary carboplatin died of progressive disease after 4 months.
Treatment is supportive for cats with carcinomatosis. Depending on the clinical condition of the cat,
intracavitary chemotherapy can be considered with the goal of temporarily reducing the effusion, though there are no
studies to indicate the efficacy of this approach. The expected survival time depends on the cat’s quality of life and
how quickly the effusion recurs after it is removed, and how uncomfortable the cat becomes and how much the cat
improves after the fluid is removed.
154
Given this information, it is important to note that although biopsy is often necessary to make the diagnosis of
mesothelioma versus carcinomatosis in cats, the distinction is primarily academic, as no definitive treatment options
are available for either condition, and the palliative care options between the two conditions are almost identical.
That being said, if owners are interesting in pursuing cytotoxic therapy, then at a minimum it is necessary to confirm
the presence of neoplasia versus inflammatory or infectious disease prior to starting such treatment.
References
1. Davies C, Forrester SD: Pleural effusion in cats: 82 cases (1987-1995). J Sm Anim Prac 37:217, 1996.
2. Amati M, Venco L, Roccabianca P, et al: Pericardial lymphoma in seven cats. J Feline Med Surg 16:507,
2014.
3. Zoia A, Hughes D, Connolly DJ: Pericardial effusion and cardiac tamponade in a cat with extranodal
lymphoma. J Small Anim Prac 45:467, 2004.
4. Garrett LD: Mesothelioma. In Withrow SJ and Vail DM, editors: Withrow and MacEwen’s Small Animal
Clinical Oncology, ed 4, Saunders Elsevier, 2007, p 804.
5. Bacci B, Morandi F, De Meo M, et al: Ten cases of feline mesothelioma: an immunohistochemical and
ultrastructural study. J Comp Pathol 134:347, 2006.
6. Reetz JA, Buza EL, Krick EL: CT features of pleural masses and nodules. Vet Radiol Ultrasound 53:121,
2012.
7. Kovak JR, Ludwig LL, Bergman PJ, et al: Use of thoracoscopy to determine the etiology of pleural effusion in
dogs and cats: 18 cases (1998-2001). J Am Vet Med Assoc 221:990, 2002.
8. Hirschberger J, Pusch. Fibronectin concentrations in pleural and abdominal effusions in dogs and cats. J Vet
Intern Med 10:321, 1996.
9. Jeglum KA, Whereat A, Young K: Chemotherapy of lymphoma in 75 cats. J Am Vet Med Assoc 190:174,
1987.
10. Vail DM, Moore AS, Ogilvie GK et al: Feline lymphoma (145 cases): proliferation indices, CD3
immunoreactivity and their association with prognosis in 90 cats receiving therapy. J Vet Intern Med 12:349,
1998.
11. Simon D, Eberle N, Laacke-Singer L, et al: Combination chemotherapy in feline lymphoma: treatment
outcome, tolerability, and duration in 23 cats. J Vet Intern Med 22:394, 2008.
12. Vail DM: Feline lymphoma and leukemia. In Withrow SJ and Vail DM, editors: Withrow and MacEwen’s Small
Animal Clinical Oncology, ed 4, Saunders Elsevier, 2007, p 733
13. Elmslie RE, Ogilvie GK, Gillette EL, et al: Radiotherapy with and without chemotherapy for localized
lymphoma in 10 cats. Vet Radiol 32:277, 1991.
14. Spugnini EP, Crispi S, Scarabello A, et al: Piroxicam and intracavitary platinum-based chemotherapy for the
treatment of advanced mesothelioma in pets: preliminary observations. J Exp Clin Cancer Res 27:6, 2008.
15. Sparkes A, Murphy S, McConnell F, et al: Palliative intracavitary carboplatin therapy in a cat with suspected
pleural mesothelioma. J Feline Med Surg 7:313, 2005.
Track B
NOTES:
155
NOTES:
Track B
156
Understanding the Cat & Feline-friendly Handling: Part 1 & 2

Ilona Rodan, DVM, DABVP (Feline)
Introduction
Understanding the cat and the causes of its fear surrounding the veterinary visit can help us improve the
experience for patients, clients, and team members. As solitary hunters, cats must protect themselves and avoid
danger, but unfortunately everything associated with the veterinary visit – carrier, car, the handling and the practice
environment– all spell danger to the cat.
Recognizing the causes of fear surrounding the veterinary visit, and taking measures to prevent fear at each
stage will facilitate the experience for all involved. Fear starts before the cat arrives at the veterinary practice, making
client education an important aspect of our care. The practice environment and respectful handling techniques
reduce fear.
Cats have a heightened fear response that acts as an important protective mechanism in threatening or
unfamiliar situations such as veterinary visits. Recognizing how the individual patient reacts to fear (i.e., attempting to
hide, run away, or show aggression) and developing handling techniques specific to the different fear responses
improves patient outcomes and prevents injury for all involved.
Understanding the Cat and Why it is Fearful

Cats are solitary hunters, who have retained many of the behaviors of their wild ancestors, Felis sylvestris
1,2
lybica. They must maintain their physical health and avoid danger, to remain successful hunters of multiple small
meals each day. They do so through protective mechanisms, which include territoriality, heightened fear response,
keen senses, and communication. The cat has a heightened fear response that is used to protect or distance self
from potential danger.
The Territorial Cat

Maintaining familiar territory allows a sense of control over the cat’s physical and social environment,
3,4
increasing security and reducing stress. Taking the cat out of its familiar territory or having an unfamiliar individual
enter their territory – for example, to go to the vet or for the vet to go to the home – can lead to fear.
5
Heightened Fear Response:
Three major responses may be exhibited in response to a potential threat, which are avoidance (fleeing),
6 .7
inhibition (freezing), and repulsion (aggression). Cats that are fearful are often inactive and quieter, attempting to
protect themselves from potential threat by trying to hide (freeze). Fear responses can change quickly based on how
we respond to the cat. For example, if we provide a space such as the bottom half of the carrier or a tall-sided cat
bed for the inhibited, quieter, and less active cat to feel hidden, we can prevent escalation of fear and aggression. If
the cat flees to avoid the situation, attempts to capture the cat will increase fear as well as the potential for
aggression. If the cat is already aggressive, it should be addressed with a different approach.
Feline Senses
Feline senses are adapted for both self-protection and successful hunting. These keen senses are often
superior to ours and can lead to increased fear during veterinary visits. Because the cat’s vision is specialized to
identify rapid movements to successfully catch prey, rapid movements occurring in the veterinary hospital can arouse
8
fear. Cats can hear very high frequencies including the ultrasonic chatter of rodents. Loud and unfamiliar sounds can
be frightening. Most importantly, the cat has an acute sense of smell, and feline pheromones are important in feline
communication. Unfamiliar scents can frighten and arouse cats. Providing familiar scents such as that of a favorite
person can help a cat adapt to new situations. Synthetic feline facial pheromone analog mimics the natural
pheromone that is deposited when a cat rubs its face on objects, and has been shown to provide a calming effect in
Para-professional
9,10,11
unfamiliar or stressful environments or situations.
Feline Communication
Feline communication acts to prevent altercations with other cats over food and territory, and avoid the risks
12
of active fighting. Fighting only occurs when other means of communication have failed. Cats communicate with a
range of subtle body postures, facial expressions, and tail positions to diffuse tension and avoid physical contact with
unfamiliar cats. Body postures help us identify a fearful cat from a medium-ranged distance. Facial signals, especially
changes in pupils and ear position, change more rapidly than body postures and provide more immediate indications
3,12
of a cat’s fear and aggression level.
157
Understanding the Cat and its Fears Surrounding the Veterinary Visit
There are many stages of the veterinary visit that can result in fear. Many cats are fearful by the time they
get to the veterinary practice. Others become fearful during examination or hospitalization. Potential causes of feline
fear are noted in Table 1, starting at home with the owner’s unusual behavior trying to get the cat into the carrier and
their own stress negatively impacting the cat.
Preventing Fear Prior to the Veterinary Visit

Client Education
Client education to facilitate veterinary visits should start during the first veterinary appointments. Owners
should be instructed about socialization their cat through positive experiences with people, and how to perform home
maintenance procedures (e.g., nail trimming) at home.
Carrier training at this early stage of adoption –regardless of the cat’s age – can prevent fear associated with
the carrier and the stress of owners chasing their cat to catch it and then shoving it into a carrier.
Also make clients aware that their stress can make their cat more fearful, and that a calm attitude
surrounding the veterinary experience can reduce the stress of the visit for both the cat and themselves.
Carrier Training
Educate cat owners to keep the carrier in a room where the cat likes to be so that it becomes familiar. Soft
bedding, preferably with the cat’s or favored owners scent, should be placed within the carrier. Most importantly,
instruct owners to allow the cat a sense of control or choice to enter the carrier instead of encouraging them to go
near or into the carrier. Positive reinforcement through treats will entice the cat to enter the carrier of its own accord.
It may take days to weeks, but it will prevent a lifetime of fear associated with the carrier.
Travel should be on an empty stomach to prevent motion sickness, and increase interest in treats at the
veterinary hospital, allowing for a more positive experience. A synthetic feline facial pheromone (FFP) analog
13
sprayed into the carrier at least 30 minutes before travel, has a calming effect on the cat. Draping a blanket over
the carrier can also help prevent fear and motion sickness. If the cat is still nauseous – lip-licking, drooling, or
14
vomiting during transportation - maropitant (Cerenia) is recommended to prevent motion-sickness. Anti-anxiety
Para-professional
medication may also be needed (see future visits). Making the visit flow more smoothly from beginning to end
The Waiting Area

The cat should be taken directly into the examination room if at all possible. If it must be in the waiting area,
provide a separate cat waiting area, and place the carrier on a chair or table, and facing away from other animals and
with a towel to cover the carrier. Use Feli-way on the towel and in each location of the hospital where cats may go.
The History
If the cat is not highly aroused when placed in the exam room, allow the cat a sense of control by obtaining
the history with the carrier on the floor, and with the door open so that the cat can come out and inspect the
158
environment on its own. It the cat is highly aroused, cover the carrier with a large towel – either one from home or
one sprayed with feline pheromone analog spray – over the carrier to block the cat’s vision of us.
Examination
Examine the cat where it chooses to be – on a lap, on the floor, a bench or in the bottom half of the carrier.
Many cats prefer to remain in the bottom half of the carrier for as much of the examination as possible. Some cats do
well also on our lap or the lap of the client’s as long as the cat is calm in their lap. When we sit on a stool near the
client with the cat in our lap, we are now on the same physical level as the client (as most clients tend to sit on the
chairs/benches in the exam rooms), which creates the sense of being an equal partner with the client in the care of
their cat. This increases value and respect by the client for what we do and how we do it. When we are standing and
the client is sitting, the height difference is huge, conveying different levels that can create a barrier to engaging the
client. Also, without a physical barrier, such as an exam table between us, the communication is more open.
To prevent both fear and pain, it is best to take the cat out of the carrier only once; for example, the exam
can be done in the bottom half of the carrier, ending with the weight. After weighing, collect lab samples if indicated.
It is much less stressful for the feline patient if lab samples are collected in the examination room instead of the
treatment area. Once a cat has acclimated to one room, the stress of moving to another alerts the cat once again to
potential danger, increasing blood pressure and other parameters.
If the client brings in more than one cat for an examination, and the cats are not getting along well in the
unfamiliar environment, or if one cat is very stressed, separate the cats into different examination rooms, and work
with each individually. Discuss the potential problems and how to deal with them if the cats still don’t get along well
when they return home.
Lab Sample Collection

Collect samples with the least amount of people and minimal handling. Usually only one holder is needed.
Speak softly or distract with food, treats, or toys. Allow the cat to remain in a natural position, and without stretching
or holding legs tightly; this prevents both pain and fear. Have a blanket or something soft for them to lie on,
preferably one that smells like home. Older, arthritic, and underweight cats are especially uncomfortable on cold and
hard surfaces, and need thick padding or fleece underneath them. Gently wrapping the cat in a towel can increase
security.
Senior cats and cats of any age with chronic kidney disease or hyperthyroidism should have blood pressures
measurements taken. Blood pressure should be measured before other diagnostic tests, while keeping the patient as
relaxed and calm as possible to avoid white coat hypertension. The environment should be quiet, away from other
15
animals and generally have the owner present. Measuring blood pressure is usually best conducted in the exam
room, rather than in the treatment area, because it takes 5-10 minutes for the cat to acclimate to a new room;
obtaining the history and performing the examination prior to blood pressure measurement will take approximately
15,16
that time, allowing the cat to adapt to the exam room.
It is best to collect all lab samples in the examination room to prevent additional fear for the cat. Many clients
prefer to watch blood pressure evaluation, venipuncture, and cystocentesis instead of worrying about what’s
happening to their cat “in the back”. It is great client education and increases perception of value. If the client prefers
not to watch, they can wait in the reception area while samples are collected in the exam room. When all procedures
are completed, allow the cat to return to the carrier if it wishes to while the client is educated about necessary
treatments and next veterinary visits.
The above applies as well if fine needle aspirates or samples for a dermatologic workup are taken. Pain relief
should be given if these conditions are painful.
Radiographs
Since more exact positioning needs to occur for radiographs, pre-treating with buprenorphine is helpful.
Sedation is indicated for fear aggressive cats and those that still resist handing despite opioid treatment.
General Handling Principles to Reduce Feline Fear

The following handling principles will improve the veterinary visit for all involved:
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• Give the cat a sense of control.

• The fewer the handlers, the better.
• Stay calm and speak in a soft voice.
• Move slowly to obtain quicker results.
• Do not stare at the cat, but rather look from the side or “wink”.
• Cats like the familiar – train the cat to the carrier and have owner bring what’s familiar.
• Scent is important in the cat’s world - use synthetic feline pheromones and eliminate scents that are
offensive to the cat.
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• Cats prefer to be massaged or petted around the face – under the chin, in the cheek area, and between
the ears – always try to do this instead of scruffing or “clipping”, which don’t allow the cat a sense of
control.
• Cats want places to hide (boxes, towels or blankets, tall-sided cat beds)
• When cats feel more secure, they also like places to perch to oversee their environment (kitty
condominiums, the top of a box, shelf, etc.
• Reward desired behavior – punishment usually exacerbates the problem
• Stand to the side instead of looming over the cat – we are big and scary! – when getting out of a carrier
or cage.
Getting a Cat Out of a Cage

If cats have options of hiding places and perches, they will be more secure in the environment, and there are
other options to remove the cat from the cage instead of pulling the cat out of the cage against its will. If the cat is in
a cat bed or basket, remove the bedding as well so that the cat can remain in the bedding.
Stand to the side of the cage instead of in front of the cage, which can be threatening to the cat. Put your
hand out calmly and slowly and let the cat choose whether it wants to come to you and even rub on you. Then gently
and calmly remove the cat from the carrier.
Preventing Fear at Future Visits

Alprazolam and gabapentin are both medications that are helpful to prevent fear or anxiety at future
veterinary visits. The author’s preferred medication is gabapentin,100mg per cat given 90 minutes prior to the
veterinary visit.
Differentiating Handling Based on Fear Responses

Recognizing the cat’s 3 major fear responses –what we would see is hiding vs. fleeing vs. aggression - and
developing specific handling techniques individualized to the response prevents human and feline injury.
Differentiating between fearful and non-fearful cats is also important - and more complicated than it sounds –
so that we can reduce fear or help the non-fearful cat continue to have positive veterinary experiences. Developing
handling techniques based on the different fear responses greatly improves the veterinary experience and safety of
all.
Handing the Non-fearful Cat

The primary goals of working with non-fearful cats is to prevent fear during the current and subsequent
veterinary visits. These patients should still be provided with respectful handling, and a safe and comfortable
environment. Even if the cat appears affectionate and content, provide an option for hiding and offer treats to distract
the cat. Since a sense of control increases security, allow the cat to choose to remain in the carrier or to come out on
its own to inspect the exam room.
Kittens and cats that are not fearful can often be distracted with canned food, treats, or baby food given
during examination and procedures. Many cats enjoy catnip that can be offered unless it is known that it will increase
arousal. Some cats, and especially kittens, will enjoy playing with toys during the visit.
Client education to carrier train cats will further the prevention of fear during upcoming veterinary visits. This
is on by making the carrier a comfortable resting area in the home, and reinforcing and rewarding with treats. For
more information, see the previous proceedings, ‘Understanding the Cat and Owner and Getting Them Back into
Your Practice’. Encourage clients to also bring familiar bedding or cat bed, treats, or toys to future visits to increase
positive veterinary experiences. Pheromone therapy may also be helpful.
Handling the Fearful Cat that tries to Hide or ‘Freezes’ (inhibition)

The most important step to take with these patients is to provide a hiding place. It is important to recognize
that hiding is an important coping strategy when a cat feels threatened, such as in an unfamiliar environment. Hiding
means that the cat is hidden so that it does not need to see us; this is usually best by facing the cat so that the head
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is looking forward or hidden within a towel, while the handler works from behind or the side. A preferred option is to
allow the cat to remain in the bottom half of the carrier if the cat has not ventured out of its own accord. A towel may
also be used to cover the carrier so that the cat does not need to see the unfamiliar. Other hiding options are a cat
bed with high sides or an igloo shape, or a towel loosely surrounding the cat.
As with the non-fearful cat, carrier training, bringing familiar and favored items from home and use of
pheromone therapy can help comfort the fearful cat. Anti-anxiety medication may be indicated.
Handling the Cat that ‘Flees’

Chasing a cat that flees will exacerbate fear and increase the potential for self-protective aggression.
Instead of chasing or trying to catch the cat, give the cat time to calm down and the option to return to the carrier.
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Decreasing arousal can take time, and it is often best to keep the cat for awhile in a calm environment and
with treats placed on the floor and in the carrier.
If the owner does not wish to leave the cat or if the cat is highly aroused, another option is to reschedule the
appointment in addition to providing client education about carrier training and bringing familiar objects to the visit.
These cats often require an anxiolytic for upcoming visits.
Handling the Aggressive Cat

It is important to remember why the cat is aggressive. This is not a ‘bad’ or ‘evil’ cat, but rather a frightened
cat that is attempting to protect self. More subtle signs are often displayed but go unrecognized until aggression
occurs. Sedation or anesthesia should be administered to prevent potential injury and exacerbated fear and anxiety
at future visits.
Don’t Forget Pain

Many cats are painful rather than fearful and recognizing the signs of pain and treating or preventing the pain
is essential. Giving analgesia preemptively or at the first sign of pain is always best.
Helpful Resources
• Rodan I, Heath S, Feline Behavioral Health and Welfare, Ed. Elsevier, Publ. 9/2015 – 3 chapters on handling
cats – the fearful cat, the cat in pain, and the challenging cat. Also, chapters on the practice environment,
including the reception area, exam room, and hospitalization and boarding areas.
• Rodan I, Sundahl E, et al, AAFP and ISFM Feline-Friendly Handling Guidelines
• AAFP Cat Friendly Practice
• CATalyst Council Handling Videos
• The Best Place to Examine a Cat: http://www.youtube.com/watch?v=izUsUH5SRUM&feature=relmfu
• Massage to calm an anxious cat: http://www.youtube.com/watch?v=6-IPmWTa_0o&feature=relmfu
• Tips for handling a fearful cat:
http://www.youtube.com/watch?v=dZDSoYyMs9Y&feature=channel&list=UL
• Handling a Cat for Lab Sample Collection:
http://www.youtube.com/watch?v=C8iAexzg710&feature=relmfu
• Getting a cat out of a cage: http://www.youtube.com/watch?v=Xr5W91nFK4M&feature=relmfu
• Cats and Carriers: Friends not Foes:
http://www.youtube.com/watch?v=9RGY5oSKVfo&feature=channel&list=UL
• Cat Clicker Training into Carrier with Dr. Jacqui Neilson and Bug:
http://www.youtube.com/watch?v=JRGKJ8FCH94&feature=channel&list=UL and
http://www.youtube.com/watch?v=b6Bz6K6HqXg&feature=channel&list=UL
• Tips for taking your cat to the veterinarian:
http://www.youtube.com/watch?v=VAaGJTcX0zI&feature=channel&list=UL
• Rodan I, Understanding the Cat and Feline-friendly Handling, in The Cat: Clinical Medicine and Management,
ed., Little S, Pub. Elsevier, pp. 2-18.
• Yin S. Low stress handling, restraint and behavior modification of dogs & cats (book and DVD). CattleDog
Publishing, 2009.
References
1. Driscoll CA, Menotti-Raymond M, RocaAL et a l.: The Near Eastern origin of cat domestication, Science
317:519, 2007.
2. Bradshaw JWS, The Behaviour of the Domestic Cat, CABI Publ, 1992.
3. Rochlitz I, Housing and Welfare, in The Welfare of Cats, Ed., Rochlitz, 2007, pp. 177-203.
4. Rand JS, Kinnaird E, Baglioni A, et al: Acute stress hyperglycemia in cats is associated with struggling and
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increased concentrations of lactate and norepinephrine. J Vet Intern Med 16:123-132, 2002.
5. Griffin B, Hume KR: Recognition and management of stress in housed cats, in August J (ed): Consultations
in Feline Internal Medicine, vol 5. St. Louis, Elsevier, pp 717-734, 2006.
6. Karagiannis C, Heath S, Understanding Emotions, In: Rodan I, Heath S, ed. Feline Behavioral Health and
Welfare. St Louis: Elsevier; 2015: 223-229.
7. Milgram NW, de Rivera C, Landsberg GM. Development of a model to assess anxiety in cats. In: Mills D, da
Graca Pereira G, Jacinto DM, eds. Proceedings of the 9th International Veterinary Behaviour Meeting.
Lisbon, Portuga: Psi Animal (Portuguese Association of Animal Behaviour Therapy and Welfare); 2013:46–
47.
8. Neville PF, An ethical viewpoint: The role of veterinarians and behaviourists in ensuring good husbandry for
cats, J Fel Med Surg 2004 6: 43.
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9. Kronen PW, Ludders JW, Erb HN, et al: A synthetic fraction of feline facial pheromones calms but does not
reduce struggling in cats before venous catheterization. Vet Anaesth Analg 33:258-265, 2006.
10. Griffith CA, Steigerwald ES, Buffington CA: Effects of a synthetic facial pheromone on behavior of cats. J Am
Vet Med Assoc 217:1154-1156, 2000.
11. Gaultier E: Current research in canine and feline pheromones, Vet Clin North Am Small Anim Pract, 33:187,
2003.
12. Bowen J, Heath S: An overview of feline social behaviour and communication, in Behaviour Problems in
Small Animals: Practical Advice for the Veterinary Team, ed 1. Saunders Ltd., p 29, 2005.
13. Pageat P, Gaultier E: Current research in canine and feline pheromones, Vet Clin North Am Small Anim
Pract 33:187, 2003.
14. Hickman MA, Cox SR, Mahabir S et al: Safety, pharmacokinetics and use of the novel NK-1 receptor
antagonist maropitant (Cerenia) for the prevention of emesis and motion sickness in cats, J Vet Pharmacol
Ther 31:220, 2008.
15. Brown S, Atkins C, Bagley R, Carr A, Cowgill L, Davidson M, Egner B, Elliott J, Henik R, Labato M, Littman
M, Polzin D, Ross L, Snyder P, Stepien R, Guidelines For the Identification, Evaluation, and Management of
Systemic Hypertension in Dogs and Cats, ACVIM Consensus Statement, J Vet Intern Med, 2007; 21: 542-
558.
16. Love L, Harvey, R, Arterial Blood Pressure Measurement: Physiology, Tools, and Techniques, in
Compendium, pp. 450-461, June 2006.
NOTES:
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Kitties in Crisis: Emergency Care for Cats

Erica Mattox, CVT, VTS (ECC)
What is a Feline Emergency?

What is a feline emergency? According to the Veterinary Emergency and Critical Care society emergency
care is defined as the action taken in response to an emergency. The term implies emergency action directed
towards the assessment, treatment, and stabilization of a patient with an urgent medical problem. In the initial phases
of emergency treatment you should always treat the patient according to clinical signs. If immediate diagnosis cannot
be identified address the patients needs.
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.
Challenges of feline patients in emergency include; different responses to shock then other veterinary
patients such as; bradycardia, hypothermia, hypotension. These patients also exhibit behavior challenges such as;
aggression, fear, increased stress, and hard to identify pain symptoms.
Feline Shock
Shock is an imbalance between oxygen delivery and oxygen consumption of tissues. When oxygen delivery
is less then oxygen consumption it can lead to lactic acid production, intracellular acidosis, decreased intracellular
enzyme function, and decreased activity of the sodium potassium pump. When activity of the sodium potassium
pump is decreased it can lead to the following; cell swelling, loss of function, cell death, cytokine release, further cell
damage leading to death, and systemic inflammation leading to organ damage and failure.
Shock can be determined by evaluating perfusion parameters. These include mentation, heart rate, pulse
quality, mucous membrane color, capillary refill time, and extremity-core temperature gradient. Clinical signs of cats
in shock include; poor pulses, prolonged capillary refill time, cold extremities, hypothermia, jaundice, and
bradycardia.
Attempts have been made to standardize the categories of shock. It is often broken down into different categories
based on the underlying disease processes. It is important to remember that different diseases can overlap into
multiple categories. Shock can be identified in the following classifications; hypovolemia, metabolic, distributive,
cardiogenic and obstructive.
Hypovolemic shock is due to impaired perfusion secondary to decreased effective circulating volume and is
often a result of; hemorrhage, internal fluid loss, severe dehydration, neoplasia, or burns. Venous return is reduced,
which leads to decreased cardiac output. This is one of the most common presentations of shock that we see in
small animal medicine.
Metabolic shock occurs due to an inability when the cells are unable to produce an adequate amount of
energy. This is often a result of disruption of cellular metabolism due to cellular membrane damage and protein
degrading and often an observed in; hypoglycemia, heatstroke and severe hypoxemia.
Distributive shock is a class characterized by syndromes that result in inappropriate vascular tone,
vasodilation, and impaired microcirculation by misdistribution of vascular volume. This can be seen with SIRS, sepsis
or anaphylaxis.
Cardiogenic shock is due to mechanical obstruction to cardiac filling that leads to inadequate cardiac output
that is due to any sort of cardiac disease such as; dilated cardiomyopathy, severe arrhythmia, valvular disease,
obstructive pericardial disease. It is crucial to differentiate this state of shock from other categories since the
traditional treatment of shock (aggressive fluid therapy) will make cardiogenic shock worse.
Obstructive shock is a decrease in blood flow to or from the heart. This can be due to disease processes
such as pericardial effusion or gastric-dilatation and volvulus. Hypovolemic and Cardiogenic shock are the most
common experienced by feline patients.
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Hypovolemic and Cardiogenic shock are the most common experienced by feline patients.
Shock can be broken into four phases; initial stage, compensatory shock, decompensatory shock, and
refractory shock. Initial stage is when inadequate oxygen delivery causes tissue hypoxia. Anaerobic metabolism
ensues creating lactic acid and pyruvic acid build-up, causing metabolic acidosis. The liver removes these acids and
requires oxygen but it is unavailable. Compensatory shock is due to systemic acidosis where patients will vasodilate
and hyperventilate to rid the body of carbon dioxide. Hyperventilation also increases preload. Decreased cardiac
output and hypotension cause baroreceptor mediated reflex. Compensatory hormones are released from the adrenal
glands. Norepinephrine and epinephrine cause an increase in heart rate contractility, and systemic vascular
resistance. Cortisol enhances catecholamine effects on arterioles. Sodium and water are conserved via renin-
angiotensin and aldosterone activation in an effort to increase intravascular volume. Vasopressin is also released
causing vasoconstriction in kidneys, gastrointestinal tract, and other organs, in an effort to divert blood flow to the
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heart, lungs, and brain. Decompensatory shock is initiated if the crisis is not corrected. Shock proceeds to
progressive stage and compensatory mechanisms begin to fail. Anaerobic metabolism continues and metabolic
acidosis worsens, causing arteriolar smooth muscle to precapillary sphincter relaxation leading to peripheral pooling
of the blood. Hydrostatic pressure increases causing leakage of fluid increases blood viscosity which can cause
hypercoagulable state. Continued shunting of blood from intestinal tract can cause ischemia and mucosal acidosis,
increasing bacterial translocation, leading to endotoxic shock. Shunting from kidneys can induce renal tubular
necrosis. Refractory shock is when irreversible tissue death has occurred and vital organs have failed. Death is
imminent. In cats hypotension is due to vasoconstriction with Bradycardia (heart rate less than 140 beats per
minute). It is observed with pale pink, gray, or white mucous membranes and a reduced to absent capillary refill time.
Pulses are often weak to non-palpable. Higher surface area in relation to body mass ratio contributes to hypothermia
is identified as body temperatures 98.6F or lower. Cats experience increased susceptibility to rapid heat loss and
less efficient compensatory heat production.
Treatment
The treatment of shock is to maximize oxygen delivery to the tissues. Oxygen delivery is equal to cardiac
output multiplied by oxygen content of circulating blood. Each of these components should be addressed when
treating shock.
Fluid therapy will improve cardiac preload and subsequently improve stroke volume. Cardiac output is equal
to heart rate multiplied by stroke volume. Fluid therapy is an integral part of treatment in all categories of shock
except cardiogenic shock resulting in low cardiac output heart failure. Fluid therapy should be used with care in feline
patients. Due to the lungs being the shock organ, cats are very susceptible to pulmonary edema and fluid overload.
The shock bolus in cats is 60mL/kg of isotonic crystalloid fluids or 3-5mL colloid intravenously. This bolus
should be given in small increments of 15 to 30 mL/kg over 15 to 20 minutes until perfusion parameters are improved
or the full 60mL/kg is reached. The administered crystalloid fluid rapidly distributes into the extracellular fluid
compartment so that only approximately 25% of the delivered volume remains in the intravascular space by 30
minutes after infusion and some animals will require additional resuscitation at this point. If perfusion parameters
such as; pulse quality, heart rate and CRT are not improved with crystalloid fluids then a colloids should be
administered. The dose of colloid solutions should be 2 to 3ml/kg over 15 to 20 minutes.
Successful treatment of cardiogenic shock depends on rapid evaluation of signalment, a brief physical
examination, and avoidance of stress. The diuretic furosemide administered intravenously or intramuscularly is a
mainstay of therapy for congestive heart failure. Ultimately, the dyspnic patient in cardiogenic shock that fails to
respond to therapy should be anesthetized, intubated, and positive pressure ventilated with 100% oxygen to stabilize
the animal, remove the anxiety associated with shortness of breath, and allow the clinician to perform a thorough
physical examination and pursue further diagnostics. The initial fluid bolus should be warmed if the patient is
hypothermic. External rewarming should be initiated in a hypothermic patient after the first fluid bolus has been given.
Starting external rewarming can cause vasodilation that will antagonize hypoperfusion without fluid resuscitation.
Cats generally require improvement in their body temperature before improvement in perfusion parameters are
appreciated.
In cats that remain hypotensive despite adequate fluid therapy and normothermia often require a
vasopressor and/or inotrope therapy. Because oxygen delivery to the tissue is dependent on both cardiac output and
systemic vascular resistance, therapy for hypotensive patients includes maximizing cardiac output with fluid therapy
and inotropic drugs and/or modifying vascular tone with vasopressor agents.
Monitoring patients in shock should continue until there is a return to normal parameters. Technicians are
essential in recognizing treatment and monitoring of patients in shock. When resuscitating a patient, whether long
term or short term, we should keep our goals in mind. These goals and signs of improvement will help us evaluate
the success of our treatments. When stabilizing a patient in shock it is important to remember we are looking for
parameters that are improving to a point considered acceptable for that disease process. Optimal resuscitation is a
return to normal parameters. This includes blood pressure, heart rate, mentation, urine production and temperature.
Continuous monitoring during initial resuscitation efforts is critical to evaluate the need for changes in treatment.
Prognosis of shock depends upon the initiating factor or disease process. Though shock can be defined in a couple
of sentences, it is not as easily classified or understood. The technician must realize that this type of patient may be
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ever changing and more than one type of shock is likely present at any given time.
Respiratory Distress
Timely assessment and intervention are crucial in the management of cats presented in respiratory distress.
These patients are critically ill and may be at risk of respiratory arrest, even with minimal handling. There are three
most common sources of respiratory distress in the cat, lower airway, pulmonary parenchyma, and pleural space.
Cats presented in respiratory distress should be immediately triaged to a quiet workspace, gently removed from their
carrier, and supplemented with oxygen. Assessment of general demeanor, mucous membranes, and auscultation of
the thorax is prioritized. Observation of the patient’s respiratory pattern should be evaluated. Cats whose respiratory
distress is severe and who do not stabilize may need more aggressive intervention including emergent anesthetic
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induction, intubation and positive pressure ventilation. The most common lower airway disease is feline asthma.
Cats experiencing an asthma attack typically have an expiratory respiratory distress due to broncoconstriction with
pronounced expiratory push. They are typically normothermic and normotensive. Thoracic auscultation of an
asthmatic patient frequently yields expiratory wheezes.
Cats with Cardiogenic pulmonary edema usually present with acute or progressive inspiratory respiratory
distress. Cats with heart disease do not usually cough and may not have a murmur. However, auscultation of a
gallop heart rhythm is nearly always indicative of significant heart disease. Crackles on auscultation are specific for
pulmonary parenchymal disease however it is not unusual for these patients to have normal or harsh
bronchovesicular sounds without crackles. These patients are often hypothermic and hypotensive secondary to low
cardiac output and poor tissue perfusion.
Cat’s with significant volumes of pleural effusion typically present with an acute or progressive history of
respiratory distress. Thoracic auscultation may reveal diminished or absent lung sounds and their pattern of
breathing is rapid, shallow and frequently frantic. This breathing pattern is commonly described as restrictive
breathing pattern. Various types of fluids that might accumulate in the pleural space and common differentials for
each include hydrothorax (serous fluids secondary to congestive heart failure are most common), chylothorax
(congestive heart failure, neoplasia, heartworm disease, and idiopathic), pyothorax (lung abscess rupture and
penetrating wound), hemothorax (trauma and coagulopathy), and other exudative processes including feline
infectious peritonitis and neoplasia. Respiratory distress acquired in the hospital is often due to pleural effusion, most
often from volume overload or previously occult cardiomyopathy.
The management of pain should also be considered in feline patients. Mentation, along with heart and
respiratory rate may be affected by pain.
Diagnostic Evaluation
Once the initial evaluation and stabilization is accomplished, the next step to addressing kitty crisis is more
in-depth diagnostic investigation. This often starts with blood work for a common emergency database such as;
PCV/TS, blood smear, BUN, Glucose, and electrolytes. A urinalysis including specific gravity is also a very beneficial
diagnostic tool. Immediate management of abnormalities associated with these tests is critical to stabilize a crisis
and prevent further decompensation. Cats in crisis often have profound metabolic abnormalities such as
hypoglycemia, hyperglycemia, hypokalemia, hyperkalemia, and hypo/hypernatremia and anemia associated with an
acute crisis presentation of disease.
Anemia is very common in critically ill cats, due to a number of reasons including smaller intravascular
volume, lower “normal” hematocrit, feline hemoglobin’s unique propensity to oxidative stress resulting hemolysis,
relatively poor regenerative capacity in cats and iatrogenic from multiple blood draws. Red blood cells should be
administered to an anemic patient to improve the oxygen carrying capacity of the blood and therefore improve
oxygen delivery. Cats are less likely to experience a splenic contraction secondary to catecholamine released during
shock then dogs to help maintain red blood cell concentrations. Red blood cell transfusions should be considered in
any poorly perfused cat with a PCV of less than 20. In cats with a coagulopathy, replacement of coagulation factors
with plasma therapy minimizes further blood loss. All kitties needing a transfusion of blood products should be typed
and crossmatched due to preformed blood type antibodies.
An example of a profound metabolic abnormality is with potassium in urethral obstruction. Hyperkalemia is a
metabolic abnormality associated with acute kidney injury or urethral obstruction. Urethral obstruction is a potentially
life threatening manifestation of feline lower urinary tract disease. Complete obstruction of the urethra leads to the
accumulation of urine and pressure within the urethra and urinary bladder. As the pressure within Bowman’s capsule
starts to exceed glomerular filtration pressure, GFR is essentially reduced to zero. Within 24-48 hours of obstruction
the kidney’s excretory ability ceases resulting in an accumulation of blood urea nitrogen, creatinine, phosphorus,
potassium, and hydrogen ion in the blood which largely contributes to the clinical signs of kitty crisis. Uremia can
cause depression, nausea, vomiting and anorexia. The combination of decreased intake and ongoing GI losses can
result in dehydration and potential hypovolemia. Severe hyperkalemia is considered to be the most life-threatening
aspect of urinary obstruction because of its effects on the cardiovascular system. Elevations of serum potassium
effect electrical conduction through the heart by diminishing the rate of depolarization resulting in bradycardia. If the
serum potassium level gets high enough, electrical activity in the heart can cease altogether resulting in asystole.
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Another example of severe metabolic abnormalities is presented in kitties experiencing a diabetes crisis or
diabetic ketoacidosis. Diabetic Ketoacidosis (DKA) is a complication of diabetes mellitus. In kitty diabetes cells
cannot use glucose and it remains in the bloodstream hence, hyperglycemia. Hyperglycemia will cause an osmotic
diuresis which predisposes the patient to dehydration. The osmotic diuresis will lead to excessive fluid loss
compounding the problem by creating hypovolemia with associated hypotension, decreased tissue perfusion, and
lactic acidosis. Meanwhile, as the cells are starved of glucose they switch to using body stores of fat and protein as
an energy source, resulting in weight loss and the accumulation of toxic products such as ketones which can cause a
diabetic crisis. These ketones are waste products of metabolizing fatty acids that build up in the bloodstream and
urine. Ketonemia further complicates the metabolic acidosis. DKA patients will show a total body depletion of sodium,
potassium and phosphorous brought about by anorexia, vomiting and the osmotic diuresis. Magnesium is also lost in
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the urine. Hypomagnesaemia may be incriminated in refractory hypokalemia. It is important when managing these
patients to evaluate the electrolytes frequently to make adjustments in therapy. How often to evaluate; will depend on
your patient’s initial condition and response to medical interventions.
Conclusion
Providing excellent patient care for the critical patient may be the difference between the patient surviving
and thriving. 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.
References
1. Carney HC, Little S, Brownlee-Tomasso D, Harvey AM, Mattox E. AAFP and ISFM Feline-Friendly Nursing
Care Guidelines: 2012. Journal of Feline Medicine and Surgery 2012 14: 337
2. Drobatz KJ, Costello MF. Feline Emergency and Critical Care Medicine. Singapore: Wiley-Blackwell; 2010
3. Silverstein DC, Hopper K. Small Animal Critical Care Medicine. Canada: Saunders; 2009
4. Mathews KA. Veterinary Emergency and Critical Care Manual. 2nd ed. Ontario: Lifelearn; 2006
5. Davis H, Jensen T, Johnson A, Knowles P, Meyer R, 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs
and Cats: 2013. J Am Anim Hosp Assoc 2013; 49:149–159
6. Murphy K, Hibbert A. The Flat Cat: 1. a Logical and Practical Approach to Management of This Challenging
Presentation: 2013. Journal of Feline Medicine and Surgery 2013 15: 175
7. Murphy K, Hibbert A. The Flat Cat: 2.The Emergency Database and Management of Common Metabolic
Abnormalities: 2013. Journal of Feline Medicine and Surgery 2013 15: 189
8. Rozanski E. Systemic Inflammatory Cat (SIC). In: Proceedings of the International Veterinary Emergency
and Critical Care Symposium; 2009: Chicago, USA. PP. 111-113.
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How to Survive the Hospitalized Cat: Feline Patient Care

Feline Patient Care

Veterinary medicine is a combination of science and art. Science uses research evidence and data to guide
it, while the art of healing relies on clinical experience, observation, patient or client feedback and the ability to
interpret the patient’s state of mind. The patient’s behavioral response to treatment is the central focus in the art of
patient care.
Feline patient care can be defined as any interaction between the patient and the veterinary team in the clinic
that promotes wellness or recovery from illness or injury, and addresses the patient’s physical and emotional well
being. In order to fully appreciate the needs of patients we must have a thorough understanding of a broad range of
both medical and surgical disorders. In critical patient care, a good knowledge of possible complications is essential
for their early recognition, and thereby the prevention of potentially life-threatening abnormalities.
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.
Minimizing Stress
One of the most important factors in creating a successful hospital experience is minimizing stress.
Preventing stressful situations should start with anticipation. Cats are notoriously sensitive to their environments.
They have a well developed fight or flight response which is a self-protective response. These responses cause
suppression of normal behaviors such as; resting, eating, grooming, and promote dysfunctional signs, anorexia,
vomiting, and diarrhea or lack of elimination. Adverse effects of stress also include undesirable physiological
responses; hyperglycemia, decreased serum potassium concentrations, elevated serum creatinine phosphokinase
concentrations, lymphopenia, neutrophilia, erratic response to sedation and anesthesia, immunosuppression,
hypertension, cardiac murmurs. These changes can complicate clinical evaluation and treatment of cats, and prolong
hospitalization.
Common stressors include; other animals and humans, noise, medical equipment, telephones, barking,
human conversation, smells and odors, disinfectants, a cage environment that does not allow hiding, unfamiliar
caretakers, unfamiliar food and feeding routines, sensory overload from busy hospital environments.
Recognizing stress should be a skill learned by every team member treating these patients. These signs include;
changes in ear position, eyes and facial expression, body posture, sweating from paw pads, tail movement,
attempting to escape, vocalization, biting, scratching, attacking, freezing; including immobilization, silence and wide
eyes.
Reducing stress in diagnostics will not only prevent abnormalities associated with stress responses but
ensure the safety for staff and patient. Choosing a quiet, undistracting place for procedures is a simple but effective
way to start. Care in positioning of older or injured cats is essential to prevent pain and unwanted behaviors.
Venipuncture and catheter placement should be done quickly by a skilled staff member. For intravenous catheters
topical anesthetics have been reported to aid in quick and calm placement. Use as little bandaging material as
possible to prevent stress from confinement. Subcutaneous fluid should be given in a calm environment. Choices can
be made in reference to type and speed at which fluids are administered to increase patient comfort.
Diagnostics
Understanding diagnostics findings is also important for technicians. Diagnostics are ordered by the
veterinarian but the technician should be involved in more than just knowing how to run the machines. It is important
to recognize key values that my indicate changes in a patients status. This leads to understanding the treatments
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that will be implemented by the technician.
Environment
Kitties need first class accommodations when staying in the hospital. Cages should be large enough to
accommodate a place to hide and for the litter box to be away from food, bedding and water. Provide familiar
bedding, toys, food and litter from home if possible and only remove when soiled. Cats prefer to be in warm, dimly lit
environments.
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. Some good old fashioned tender loving care should be administered
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often. Keep cats in areas away from other animals as much as possible. Environmental enrichment such as allowing
brief periods of exercise out of cage in quiet room will improve elimination, as well as eating and grooming habits.
Nutrition
Providing nutrition is very important for hospitalized patients. Most nutritional supplementation is ultimately
decided by the Veterinarian but monitoring and recommending nutritional intervention is something technicians
should be trained to do. Also, understanding the appropriate time and technique to carry out the nutrition plan is vital
for the recovery of most hospitalized veterinary patients and something technicians should understand and be
involved in. Cats are true carnivores and they have high dietary protein requirements. Catabolism of body protein for
gluconeogenesis occurs rapidly following anorexia and illness which leads to hepatic lipidosis. There are many tips
for encouraging kitties to eat such as types and temperature of food, and food presentation. Appetite stimulants and
enteral nutrition should be initiated sooner than later in anorexic kitties. Nursing staff should be advised of food
aversion.
Pain Management
Feline patient care technicians should be encouraged to make pain assessments based on changes in
patient’s behaviors in the hospital. Patient care technicians normally spend the most time with the hospitalized
patient and should be able to pick up on subtle cues associated with patients experiencing changes in pain status. To
keep pain assessments more objective, the use of pain scores by a knowledgeable staff is important. The pain
assessment also involves recognizing when pain therapies are working and can confidently suggest other options for
their patients. Many studies have shown the negative results of chronic pain for patient outcomes. Assessing pain in
feline patients can be difficult. Patients should be evaluated from a distance. Closely observe posture, gait and
movement, respiratory rate, vocalization, and anxiety, licking or chewing, aggression or submission, restlessness,
reluctance to interact, or anorexia.
Owner Care
Technicians should be knowledgeable and compassionate whenever speaking with owners of a hospitalized
patient. In order for clients to make rational decisions regarding their pet’s care, it is important that they trust the
veterinary team and that time is spent explaining the nature of the animal’s problems, possible treatment options,
complications and prognosis. The owner should be made to feel at ease and to have confidence that their pet is
being cared for in a professional and pleasant environment. The technician often plays a vital role in client
communication.
Help owners identify a familiar, private space at home where they can easily access their cat. Encourage
them to establish a routine with medication. Instruct owners to not forcibly remove cat from hiding or interrupt eating,
grooming or elimination to administer medication. Make sure owners know what healthy cat behaviors are.
Encourage open communication with owners and provide alternatives for treatment if necessary.
Kitties often do not receive the care they need because of owner anxiety. A veterinary team that is knowledgeable
and skilled in working with kitties will ease the stress of not only kitty patients but kitty clients. Owners can often
detect which team members truly connect with their cats. To provide optimal support to a well, sick, injured or
recovering cat, the art of nursing care is as important as medical science.
References
3. Silverstein DC, Hopper K. Small Animal Critical Care Medicine. Canada: Saunders; 2009
4. Mathews KA. Veterinary Emergency and Critical Care Manual. 2nd ed. Ontario: Lifelearn; 2006
5. Davis H, Jensen T, Johnson A, Knowles P, Meyer R, 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs
and Cats: 2013. J Am Anim Hosp Assoc 2013; 49:149–159
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8. Rozanski E. Systemic Inflammatory Cat (SIC). In: Proceedings of the International Veterinary Emergency
and Critical Care Symposium; 2009: Chicago, USA. PP. 111-113.
9. Hopper K, Epstein SE, Fletcher DJ and Boller M. RECOVER Evidence and Knowledge Gap Analysis on
Veterinary CPR. Part 3: Basic Life Support. J Vet Emergency and Critical Care 2012; 22:S26-S43.
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Kitties vs. Kidneys: Feline Kidney Disease

Anatomy of the Urinary System

The urinary system is an important route of waste removal in the body. It removes nearly all the soluble
wastes from blood and transports them out of the body. The urinary system includes kidneys, ureters, urinary bladder
and urethra.
The kidneys are the functional organs of the urinary system. They filter blood and produce urine. The kidneys
are reddish-brown, bean shaped and smooth. Both kidneys are located high in the dorsal region of the abdomen.
They are behind the peritoneum and caudal to the diaphragm. The right kidney is located slightly cranial to the left
kidney. The kidneys are held in place and protected by a layer of fat. They are surrounded by a fibrous connective
capsule. The indented area on the medial side of the kidney is called the hilus. A hilus is the area where blood and
lymph vessels, nerves, and ureters enter and leave the kidney. The hilus also contains a funnel shaped area called
the renal pelvis. This area is a urine collection chamber that begins the ureters. The outer surface of the kidney is the
cortex. Within the cortex is the medulla. The medulla extends from the cortex to the renal pelvis.
The nephron is the basic functional unit of the kidney. A nephron is a microscopic filter, reabsorbing, and
secreting system. The kidney is made of hundreds of thousands of nephrons. Each nephron consists of a urine
producing tubule and a renal corpuscle. The renal corpuscle is located in the cortex and consists of the glomerulus
and glomerular capsule surrounding it. This glomerulus is a collection of arterial capillaries. The vessel entering the
glomerulus is the afferent arteriole and the vessel leaving is the efferent arteriole. The glomerular capsule or
Bowman’s capsule is a cup shaped, expanded end of the renal tubule surrounding the glomerulus. The glomerular
capsule has a visceral layer surrounding the glomerulus and a parietal layer that is an extension of the visceral layer
surrounding the urinary space creating the center of the glomerular capsule. The urinary space within the glomerular
capsule is where fluid filtered from the glomerulus through the visceral layer is collected. The urinary space drains
into the tubular portion of the nephron. The tubular area of the nephron consists of the proximal convoluted tubule,
the nephron loop and the distal convoluted tubule. The proximal convoluted tubule is the longest part of the nephron.
It is a twisted tube extending from the glomerular capsule toward the medulla where it straightens into the nephron
loop. The nephron loop or loop of Henle descends into the medulla and then ascends to continue as the distal
convoluted tubule. The distal convoluted tubule continues the nephron loop close to the glomerulus and then joins
the collecting ducts. Collecting ducts carry the urine produced by the nephron to the renal pelvis.
Each kidney has a ureter. The ureters are fibromuscular tubes carrying urine from the kidneys to the urinary
bladder. The ureters pass through the urinary bladder’s wall at the acute angle, preventing backflow and still allowing
urine to empty into a full bladder by peristaltic action.
The urinary bladder is a greatly distensible pouch receiving and storing urine from the kidneys for release out
the urethra. The empty bladder lies almost entirely within the pelvic cavity, but with distention extends into the
abdominal cavity. It has a thick wall that is lined with many thick folds of transitional epithelium. Within the walls of the
bladder are stretch receptors that trigger the urge to urinate. The bladder also contains sphincter muscles that
contract and relax to open and close the passageway for urine to enter the urethra.
The urethra is the tube transporting urine from the urinary bladder to the external urethral surface.
Urine Production
Kidneys are continuously producing urine which is the fluid that facilitates the elimination of metabolic waste
material. The three main mechanisms kidneys use to remove waste from the body and maintain homeostasis by
producing urine are filtration, reabsorption, and secretion. Filtration of blood occurs in the renal corpuscle. They
kidneys filter approximately 20% of the body’s blood. The glomerular capillaries are located between two arterioles
branching directly from the aorta which creates and area of higher blood pressure. The high blood pressure in these
capillaries forces some plasma (minus large proteins and the blood cells) out of the glomerular capillaries and into
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the urinary space of the glomerular capsule. The epithelium of the glomerular capillaries also contains many
fenestrations, larger than those in other capillaries, to facilitate fluid movement from the bloodstream. The fluid
leaving the capillaries is collected in the urinary space of the glomerular capsule and is called glomerular filtrate.
The glomerular filtrate that collects in the urinary space of the glomerular capsule contains most of the waste
products that need to be removed from the body. It also contains substances found in plasma that the body doesn’t
want to lose. Some of the most important of these substances are sodium, potassium, calcium, magnesium, glucose,
amino acids, chloride, bicarbonate and water. The mechanism or reabsorption is used by the kidneys to return some
of these substances to the blood stream.
When the glomerular filtrate enters the proximal convoluted tubule it becomes tubular filtrate. Changes to this
filtrate begin immediately. Some substances make this movement passively through osmosis or diffusion. Others
have to be actively transported across cell membranes. About 65% of all tubular reabsorption takes place in the
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proximal convoluted tubule, about 80% of the water, sodium, chloride, and bicarbonate and 100% of the glucose and
amino acids in the tubular filtrate are reabsorbed. Additional reabsorption takes place in the loop of Henle,
descending convoluted tubule, and collecting ducts.
Some waste products and foreign substances are not filtered from the blood in sufficient amounts from the
glomerular capillaries. The remaining plasma not forced out of the glomerular capillaries leaves the glomerulus and
enters a peritubular capillary network around the rest of the nephron. The body still needs to get rid of these
substances so it transfers them from the capillaries along the tubules and into the tubular filtrate. Most of this tubular
secretion takes place in the descending convoluted tube. Hydrogen, potassium, and ammonia are some of the more
important substances eliminated by secretion.
Urine volume is determined by the amount of water contained in the tubular filtrate when it reaches the renal
pelvis. There are hormones produced in the body that send signals to the kidneys regulating how much water is
reabsorbed or lost in the urine.
By the time the tubular filtrate reaches the collecting ducts, it has decreased in volume, has changed
chemical composition many times, and is now ready to leave the kidney on its way to being eliminated. When the
tubular filtrate enters the renal pelvis it is urine.
Pathophysiology
Renal failure is one of the most common diseases that affect feline patients. Depending on the disease or
injury, the kidney failure may be acute or chronic. Both are indentified 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. Ultimately damage to the kidneys can be irreversible, as nephrons do not
regenerate.
Uremia is a term used to describe most of the clinical signs and clinical findings that occur with renal failure.
The most common uremic complication is the appearance of gastrointestinal symptoms such as anorexia, nausea,
vomiting and diarrhea. Other signs of uremia include polyuria, polydipsia, hypertension and anemia.
Acute Kidney Injury

Acute kidney injury is defined as an abrupt decline in glomerular filtration rate and excretory function of the
kidneys. The term acute kidney injury has largely replaced the term acute renal failure due to the growing evidence
that transient decreases in renal function, short of overt organ failure, are associated with increased morbidity and
mortality in human patients. Many diseases and injuries that cause acute kidney injury (AKI) are potentially reversible
pending diagnosis and treatment is made early. AKI results from either Prerenal, intrinsic or post renal causes.
Prerenal azotemia is not caused by primary kidney disease, but rather by a decrease in inadequate blood
supply to the kidneys. Glomerular filtration rate declines due to poor renal perfusion or increased renal vascular
resistance when mean arterial pressure falls below 60mmHg as seen in hemodynamic disturbances such as
hypovolemia or cardiogenic shock.
Intrinsic azotemia occurs from damage to the renal parenchyma, specifically to the vasculature, glomeruli,
tubular epithelium and interstitium of the kidney. In cats, the most common causes occur from toxins, infectious
diseases and ischemic causes. Some of the most common nephrotoxic drugs/chemicals in cats include ethylene
glycol, antimicrobials (gentamicin), and lilies. Kidneys are particularly vulnerable to toxins because of because of its
high rate of blood filtration. One of the most common diseases that cause AKI in cats is pyelonephritis.
Post renal azotemia causes occur from obstruction or rupture of the urinary tract system. Examples include
urolithiasis, neoplasia, prostatic disease, trauma, and feline lower urinary tract disease. Cats that have had feline
lower urinary tract disease (FLUTD) have an increased risk to becoming obstructed due to inflammation. When a cat
becomes obstructed, the pressure within the urethra and urinary bladder will be transmitted up the ureters to the
kidney’s nephrons. Eventually the pressure starts to alter the GF pressure until the filtration rate is zero.
Approximately 25% of cats that obstruct have a complete resolve of their azotemia in 2 to 5 days. Another 40%
retain mild azotemia and are successfully managed with medical treatment.
Chronic Renal Failure

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The causes of CRF are numerous and can be congenital, familial, or acquired. No matter what causes the
CRF, it is characterized by irreversible changes to the nephrons.
Congenital causes are often suspected based on the age of the cat, breed and family history. Polycystic
kidney disease (PKD) is characterized by the presence of multiple fluid filled cysts which can result in enlargement of
the kidneys.
Familial disease includes amloidosis which is found in Abyssinians, Oriental Shorthairs and Siamese.
Amloidosis occurs from an increase permeability of the glomerular membrane due to abnormal deposit of amyloid
protein within the glomerular capsule, which causes changes in the capsule resulting of protein loss.
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Acquired CRD can result from any disease process that injures the kidneys to a point where the nephrons
are no longer functioning appropriately. Some common diseases that lead to CRD include: feline infectious
peritonitis, neoplasia (renal lymphosarcoma), hyperthyroidism, and chronic tubulointerstitial nephritis.
Diagnostic Evaluation
A complete history and thorough physical exam remain paramount in patient care. Common clinical signs
include lethargy, anorexia, vomiting, and diarrhea. Patients with AKI may present with abdominal pain, renomegaly,
oral ulceration, neurologic signs and varying urine output states. Patients should be assessed quickly for signs of
dehydration and hypovolemia, such as poor pulse quality, prolonged capillary refill time, and tachycardia. The
presence of bradycardia may indicate severe electrolyte or acid-base imbalances.
A minimum database for these patients should include serum chemistry, complete blood count, urinalysis
and urine culture. While elevations in both blood urea nitrogen (BUN) and creatinine are the main characteristic
features of renal injury, creatinine is considered to be the most specific biomarker of declining renal function as it is
less influenced by other factures compared to BUN. Other common abnormalities include electrolyte disturbances
and metabolic academia. The abnormalities identified in the complete blood count are not usually specific to renal
injury but useful in assessing hydration such as hematocrit.
Urine specific gravity is essential for the assessment of renal concentrating ability when animals are
azotemic, polyuric, oliguric or anuric. Evidence of glomerular or tubular damage may present in the form of
proteinuria, glucosuria, granular casts, and/or microscopic hematuria seen on urinalysis. Calcium oxalate crystalluria
is characteristic of ethylene glycol toxicity. White blood cells and bacteria may be seen in cases of pyelonephritis, but
urine should be cultured in all cases to rule out the possibility of an occult urinary tract infection or pyelonephritis.
Diagnostic imaging in many cases will be within normal limits. Abdominal ultrasound may show normal to enlarged
kidneys with normal architecture in AKI. Hyperechoic renal cortices have been associated with ethylene glycol
toxicity.
Treatment of Renal Disease

Conventional medical management is directed towards treating the inciting causes, addressing
gastrointestinal complications, providing nutritional support and maintaining adequate urine output.
The gold standard is diuresis. It’s important to account for any body water deficits as well as any ongoing
losses such as vomiting and diarrhea. Initial solutions are generally isotonic crystalloids. While research is still
ongoing, colloid therapy should be avoided if possible in renal injury patients. Renal dysfunction has been associated
with hydroxyethyl starch solutions of all types, including high and low molecular weight solutions. In humans, there is
growing evidence that there is a dose-related association with AKI and colloids in certain subsets of patients, such as
sepsis. The mechanism for this effect is two-fold; mechanical blockage of the renal tubules and injury to the tubular
cells themselves. Although the evidence is lacking in veterinary medicine as to whether there is the same association
in our patients, it is practical to limit artificial colloid therapy in patients at high risk of renal tubular injury, or renal
failure.
Once a patient is rehydrated, technicians should ensure that the amount of fluid they are receiving is the
amount of urine they are producing. A normovolemic and normotensive patient should produce 1 to 2 ml/kg/hr of
urine. Urine production should be quantified as precisely as possible. The most accurate way of monitoring urine
production is by placing an indwelling urinary catheter. Other less accurate methods, such as intermittent
catheterization and weighing soiled urine pads can be used.
In the case of oliguria additional fluids or treatment may be required. Most commonly the loop diuretic
furosemide is chose because it helps to increase tubular and renal flow without significantly affecting glomerular
filtration. There is also some theory that furosemide may protect cells within the loop of Henle. It is important when
using furosemide to account for volume and potassium requirements so that the patient does not become
dehydrated.
Dopamine, when used in low doses, increases renal blood flow, glomerular filtration and sodium excretion.
Higher doses may cause cardiac arrhythmias, nausea, vomiting and tachycardia.
Mannitol is used to increase volume and tubular fluid flow by creating osmotic effect so that water is not
reabsorbed from the tubular lumen. Mannitol is contraindicated in patients with cardiac disease, overhydration or
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dehydration because of its complication to cause volume overload and pulmonary edema.
There is no evidence that diuretic therapy will improve renal recovery in human or veterinary clinical trials.
Many studies have shown a clear increase in urine output with diuretic therapy but this has not translated to an affect
on patient outcome. Therefore, whether these diuretics should be used in the veterinary ICU is an ongoing
controversy. Diuretics are no longer routinely recommended for management of human renal injury, as it may delay
the initiation of renal replacement therapy. In veterinary patients, where cost and availability limit the use of renal
replacement therapy, increased urine production may allow the administration of fluids, medication, and nutrition that
would otherwise lead to volume overload.
Acid-base status and electrolytes must be constantly monitored. Metabolic acidosis and hyperkalemia are
common in oliguric ARF patients and is commonly seen in feline urethral obstruction patients.
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In severely hyperkalemic patients, bradycardia peak T waves, loss of P waves and life threatening cardiac
arrhythmias can be seen. In such severe cases, treatment should be initiated to help deal with the hyperkalemia. The
administration of calcium gluconate may be necessary to help prevent further cardiac toxicity. The administration of
glucose and insulin help draw potassium back into cells.
Chronic renal failure patients are more likely to suffer hypokalemia effects because the potassium is closely
regulated in the kidneys. In serum potassium levels less then 2.5 mEq/L neuromuscular signs can occur which
include a reluctance to move, a stiff gait, ventroflexion of the neck, and tremors. Intravenous administration of
potassium can be use to correct hypokalemia.
Hyperphosphatemia is commonly observed in CRD patient because the kidney plays an important role in
excreting phosphorus. Typically hyperphosphatemia does not produce clinical signs, but it can lead to the
progression of secondary hyperparathyroidism which can lead to death. Hyperparathyroidism is an overproduction of
the parathyroid hormone, which helps to regulate the levels of calcium and phosphorus in the body. It can lead to
muscle weakness and central nervous system disturbances.
Hypocalcemia is another common clinical finding of renal failure. Roughly 26% of CRF cats suffer this
electrolyte disturbance. Intravenous calcium gluconate may initially be administered to help correct any serious
hypocalcemia and then oral supplements may be used after.
Gastrointestinal complications are frequent in patient with renal injury. Gastrointestinal ulceration, whether
clinical or occult, is one of the most common of these complications. Gastrin is excreted via the kidneys, and reduced
glomerular filtration rate leads to hypergastrinemia and gastric hyperacidity. lso, Uremic toxins acting at the
chemoreceptor trigger zone, and the local effects of gastrointestinal ulceration cause nausea and vomiting.
Antiemetics should be considered.
Several studies have shown that feeding renal diets allows for longer survival times. Early enteral nutrition is
recommended in hemodynamically stable patients. Renal injury is a highly catabolic disease therefore nutrition is
essential. In combination with their already depleted protein levels, many patients are vomiting and inappetent due to
uremia. The enteral rout is preferred versus parenteral nutrition. Typically most renal diets restrict phosphate, sodium
and protein intake while allowing for adequate potassium, nutrients and calories. It is important that caloric intake is
closely monitored as many CRD patients are malnourished. For patients that are not consuming at least 70% of their
daily resting energy requirement voluntarily within a few days, feeding tube placement is strongly recommended.
Nasogastric feeding tubes are simple to place, with minimal or no sedation needed in most patients.
Over 60% of cats develop systemic hypertension from renal disease. This could be from a decrease in glomerular
filtration, inappropriate filtering of sodium and water and impaired production of renal vasodilatory substances. Signs
may include blindness, retinal hemorrhage and detachment, glaucoma, cardiac failure and neurologic signs.
Patients often suffer moderate to severe anemia with CRD. There are a number of reasons for patients to suffer
anemia including gastrointestinal hemorrhage, erythropoietin deficiency, iron deficiency and shortened red blood cell
life. Red blood cell transfusion is rarely recommended because of the decreased life span of red blood cells in uremic
patients. As the patient’s kidney values decrease, the anemia starts to resolve.
Advanced Treatments
Since 1984 the renal transplant surgery has been quite successful with more than 90% of cats surviving past
one year and most surviving to three years. Owners who wish to pursue renal transplant must be prepared for the
expensive cost and adopt the pet who donates the kidney. The actual renal transplant is long, and complications
include bleeding, hypertension, embolism, infection and rejection of the new kidney.
Dialysis is defined as movement of waste solutes and water across a semi-permeable membrane according
to their concentration gradients. The two forms of dialysis are corporal (peritoneal dialysis) and extracorporeal
(intermittent dialysis or continuous renal replacement therapy).
Intermittent hemodialysis has been a successful treatment in managing renal failure in cats. Its purpose is to
correct the effects associated with uremia by passing the blood across an artificial membrane outside the patient’s
body to allow for filtration. Most common complications include neurologic, gastrointestinal and hypertension during
the treatment.
Continuous renal replacement therapy relies on continuous gradual blood purification. The patient’s blood is
filtered until the kidney function returns to normal. It is most often used with acute kidney injury, but can be used for a
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toxic ingestion as well as to help diurese the body. The patient’s blood passes through filtration circuit tubing in a
machine to a semipermeable membrane where waste products and water are removed. Replacement fluid is added
to the blood and is returned to the patient.
Prognosis
Despite advances in treatment kidney injury remains a serious and often results in fatal disease. About 60%
of patients die or are humanely euthanized because of failure to respond to supportive care.
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References
5. Little SE, The Cat, St. Louis, 2011, Elsevier, 980.
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Trouble in the Urethra: Feline Lower Urinary Tract Disease

Feline Lower Urinary Tract Disease (FLUTD)

Feline lower urinary tract disease (FLUTD) describes a collection of conditions that can affect the bladder
and urethra of cats. This syndrome, regardless of etiology, has a number of recognizable signs such as hematuria,
stranguria and pollakiuria. There are numerous causes for these signs, and they merely localize the problem to the
bladder or urethra. In addition cats may urinate in inappropriate and unacceptable places, may vocalize or be
agitated from discomfort, and in the case of urethral obstruction, may present with dysuria. Clients may mistake the
straining for difficulties defecating. FLUTD sings can occur at any age but are usually in cats less than 1 year of age
and most frequently in cats 2-6 years of age. In older cats Neoplasia should be ruled out. When clinical signs are
considered without regard to obstruction, no difference in risk between males and females is observed. Risk factors
include indoor only cats, dry food, excessive body weight, decreased activity, multiple cat household, and Persian cat
breeds. The exact nature of these predispositions remains to be determined.
Causes or Contributers
There are many different causes or contributors to FLUTD. However, the most common of all these is
idiopathic feline cystitis (FIC). Statistics in the literature estimate that 55-64% of all FLUTD cases are due to this
syndrome. The pathophysiology of FIC is not fully understood and may involve complex interactions between several
body systems. Damage to or malfunction of the glycosaminoglycan layer of urothelium and abnormalities in local
sensory neurons, sympathetic nervous system, and central nervous system are known to occur in these patients and
results in an inappropriate release of inflammatory mediators locally. Other causes reported include uroliths, urinary
tract infections, crystalluria, urethral plugs, strictures, neoplasia, functional urethral spasm, neurologic disease and
blood clots.
Inflammation, regardless of the cause (crystals, stones, infection, or idiopathic) 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.
These clinical signs localize the problem to the lower urinary tract. 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. Regardless of the cause, life-threatening systemic effects will occur if the obstruction is not
resolved.
Non-obstructive Vs. Obstructive

Non-obstructive FLUTD signs may improve in 5 days with or without treatment. Fluids can be administered to
promote diuresis and dilute urine. Discussions with clients about husbandry and management of this disease are
critical at this point. Canned diets will increase water intake and fresh water should be available at all times.
Medications can be given to alleviate pain and inflammation, stress and urethral spasms. Recurrence rates for
FLUTD signs are high. About 50% of cats have a recurrence of clinical signs within one year. Owners of male cats
should be educated on identifying signs of urethral obstruction.
Obstructive Feline lower urinary tract disease (FLUTD) is a common veterinary emergency in feline patients.
While theoretically it can occur in both male and female, it is predominantly a male feline problem, likely due to their
smaller urethral canal. The disease does not appear to be associated with any specific breed or age. Indoor cats are
more commonly seen but that is likely due to the fact that outdoor cats urinary habits are difficult to witness and
therefore signs are often missed. Some cats with urethral obstruction may have a history of non-obstructive urinary
signs in the past but in some, this will be the first event noted by the owner. The most common historical clinical
signs noted by owners include dysuria, vocalization, depression, anorexia, vomiting, periuria, hematuria, and pain
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behaviors. On physical exam, these signs may be noted in addition to a large, turgid, painful and unexpressible
urinary bladder. Bradycardia, increased respiratory effort, hypothermia and depressed mentation are also noted.
Patients that present with bradycardia, hypothermia and obtunded should be treated as critical patients and treated
immediately.
Diagnostics
Initial diagnostics should include abdominal radiographs, urinalysis with sediment evaluation, blood
chemistry, and electrolyte evaluation. Radiographs of the abdomen can screen for urolith involvement while urine is
tested for its urine specific gravity and sediment is evaluated in a timely fashion to evaluate if crystalluria is present.
Sediments that sit longer than 30 minutes will result in exogenous crystal formation. Blood work looking at
electrolytes at presentation is most important in order to evaluate if any critical derangements such as hyperkalemia
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exists which need specific targeted therapy. A blood chemistry while helpful in obtaining baseline renal values, is not
useful as a predictive factor for prognosis, thus if not able to maintain, will not result in inappropriate care. However, it
is ideal to verify azotemia has resolved before discontinuing fluid therapy.
The most common lab work findings in FLUTD obstructive patients consist of a metabolic acidosis and
azotemia. Approximately 25%of these patients will also be hyperkalemic and 20% have been documented to have
ionized hypocalcemia usually secondary to concurrent hyperphosphatemia.
Survey and contrast radiography as well as ultrasound are routinely indicated in felines with LUTD signs.
Plain radiographs are valuable for the identification of radiodense stones in the kidneys, ureters, bladder or urethra.
They may also identify masses external to but compressing the urinary tract. Ultrasound, while non-invasive, fails to
evaluate the urethra. It images Hyperechoic material within the bladder including crystal sludge or sand, blood clots,
irregularities including thickening of the bladder wall.
Treatment
No matter whether inpatient or outpatient care is selected by the owner, there are some basic treatments
needed by both groups including relief of obstruction, reestablishment of urine flow, and correction of fluid,
electrolyte, and acid-base imbalances associated with obstruction and post renal azotemia are the first steps to
proper management.
An intravenous catheter is placed and sedation for urethral retropulsion to alleviate the obstruction is high
priority in all cases. Most cases can be treated without gas anesthesia if the right combination of anesthetic protocol
is used. While lab work should be performed, it is not necessary to await those results before starting the unblocking
procedure. Critically ill cats with urethral obstruction and severe azotemia often have decreased tissue perfusion due
to hypovolemia and cardiac dysfunction secondary to metabolic disturbances. An Electrocardiogram should be
obtained in cases of irregular heart rate or rhythm. ECG abnormalities associated with hyperkalemia include increase
T wave, decrease or loss of P wave, Prolonged PR, QRS, and QT intervals. If severe hyperkalemia is present and
causing bradycardia and cardiac electrical conduction disturbances, it should be treated immediately.
Once the obstruction has been relieved in critical cases hospitalization is often required for an extend period
of time. There are a large number of general patient care considerations and it is important to create a care plan for
each individual patient based on the uniqueness of that patient that caters to their physical, physiological, and
psychological well-being. Care of hospitalized patients should promote wellness or recovery from illness or injury.
Vital parameters of each system should be evaluated and treatment adjusted as needed.
A few patient care considerations possibly include critical patient care such as fluid resuscitation, aggressive
warming for hypothermia and monitoring to help initiate and evaluate immediate treatments. Also, hourly urine
quantification, and care of peripheral and urinary catheters is also needed. Fluid therapy and monitoring urine output
are important aspects of post obstructive care. Patients which have had prolonged obstruction due to severity of
azotemia are at risk for a post obstructive diuresis resulting in massive urine production. This diuresis is thought to
occur secondary to the accumulation of osmotically active substances in the blood, pressure necrosis, medullary
washout and antidiuretic hormone resistance brought about during the obstructive process. It is important to keep up
with urinary losses in these patients because if fluid rates do not match urine output the patient quickly becomes
dehydrated and hypovolemia. Another important consideration is analgesia and sedation. Cystitis and obstruction, in
addition to urethral catheterization, are painful and could be associated with risk of reobstruction.
Unfortunately, the ability to provide the optimal treatment course may be limited by owner financial
constraints. There is evidence that urinary obstruction is as much a mechanical obstruction (urethral edema and
spasm) as a physical one (plug or stone). A recent study has demonstrated that pharmacological manipulation with
analgesia and sedation, a low stress environment, and intermittent cystocentesis can result in spontaneous urination
without the need for catheterization. This less invasive approach was offered in lieu of euthanasia when traditional
treatment was prohibited by financial constraints.
Considerations for ongoing long term management of these cases vary. There is no preventative curable
treatment for FIC disease in cats so efforts at this time are focused on altering the diet and environment with hopes
to decrease stress, avoiding urine retention, and increasing water intake.
Diet changes especially in those cats with crystalluria have been shown to decrease recurrence of the
disease as long as the owner compliance is consistent. New diets are available and promoted even in cats that do
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not have crystalluria, as they contain other anti-stress hormones such as tryptophan. (Science Diet C/D multicare).
Since stress is thought to be a component to trigger this syndrome, environmental enrichment has been advocated in
these cats along with keeping their day to day routine and environment as consistent as possible. This means
avoiding new cats, construction, changes in litter substrate, etc.
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.
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References
1. Buffington, CA, Pandora syndrome, J Vet Internal Med, 25: 784, 2011
2. Bradley A, Lappin MR: Intravesical glycosaminoglycans as a novel therapy for feline idiopathic cystitis-a pilot
study, Abstract NU-20, Am J Vet Internal Med 26:802, 2012.
3. Cooper ES, Owens TJ, Chew DJ et al: A protocol for managing urethral obstruction in male cats without
urethral catheterization, J Am Vet Med Assoc 237:1261, 2010.
4. Gunn-Moore, D: Feline lower urinary tract disease, J Feline Med Surg 5:133, 2003.
5. Buffington CA, Westropp JL, Chew, DJ et al: Clinical evaluation of multimodal environmental modification
(MEMO) in the management of cats with idiopathic cystitis, J Feline Med Surg 8:261, 2006.
6. Little SE, The lower urinary tract in Little SE, The Cat, St. Louis, 2011, Elsevier, 980.
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Lunch & Learn
Lunch
Update on Feline Anaplasmosis
Generalist
Michael Lappin, DVM, PhD, DACVIM
Introduction
& Learn
The organisms of the order Rickettsiales, in the families Rickettsiaceae and Anaplasmataceae, were
reclassified in 2001 after phylogenetic analyses of the 16S rRNA and groESL gene sequences (Dumler et al., 2001).
Some Ehrlichia spp. were transferred to the Neorickettsia genus (including E. risticii) and some Ehrlichia spp.,
including E. phagocytophila (also previously called E. equi and human granulocytic Ehrlichia) and E. platys were
placed into the genus Anaplasma. The genera Ehrlichia and Neorickettsia were transferred to the family
Anaplasmataceae; the genera of Rickettsia and Orientia remained in the Rickettsiaceae. The organisms in Ehrlichia,
Anaplasma, and Neorickettsia are classified genetically and by cell tropism (monocytotropic, granulocytotropic, or
thrombocytotropic). The organisms of most importance to dogs and cats discussed in this chapter include A.
phagocytophilum, A. platys, Ehrlichia canis, E. chaffeensis, E. ewingii, Neorickettsia risticii, Rickettsia rickettsii, and
R. felis (Table 93-1). Prevalence rates in many countries have been determined for most agents; maps showing
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prevalence rates in the United States are published by the Companion Animal Parasite Council (www.capcvet.org).
Etiology and Epidemiology

Cats have shown to be susceptible to A. phagocytophilum infection after experimental inoculation (Lewis et
al., 1975; Foley et al., 2003). DNA of A. phagocytophilum has been amplified from blood in naturally exposed cats in
multiple countries, including Germany, Denmark, Finland, Ireland, Switzerland, Sweden, and the United States.
Morulae consistent with A. phagocytophilum have been detected cytologically in neutrophils of naturally infected cats
in other countries, including Brazil, Kenya, and Italy. Cats living in endemic areas are commonly seropositive. As in
dogs, A. phagocytophilum is transmitted by Ixodes ticks, so infections of cats are likely to be most common in these
areas. Although rodents are commonly infected with A. phagocytophilum, whether ingestion or direct contact with
rodents plays a role in A. phagocytophilum infection of cats is currently unknown. Although the pathogenesis of
disease associated with A. phagocytophilum in cats is unknown, some cats experimentally inoculated with A.
phagocytophilum developed antinuclear antibodies and increased interferon- m RNA, s ugge s ting tha t an immune
pathogenesis of disease may contribute to the clinical findings (Foley et al., 2003).
Clinical Features
Fever, anorexia, and lethargy were the most common clinical abnormalities. Tachypnea has also been
detected. Ticks may or may not currently be infesting infected cats. Overall, clinical signs associated with A.
phagocytophilum infection in cats were mild and resolved quickly after initiating tetracycline therapy.
Diagnosis
Approximately 50% of cats with proven clinical infections induced by A. phagocytophilum have a mild
thrombocytopenia (66,000 to 118,000/µL). Neutrophilia with a left shift, lymphocytosis, lymphopenia, and
hyperglobulinemia have been detected in some cats. Morulae are less commonly detected than in dogs but have
been detected in both naturally infected and experimentally infected cats. The abnormalities resolve quickly after
doxycycline treatment is initiated. Biochemical and urinalysis abnormalities are uncommon. Some commercial
laboratories offer serologic testing. Infected cats are negative for antibodies against E. canis, so A. phagocytophilum
specific assays should be used. The SNAP4DXPlus from IDEXX Laboratories has been shown to detect A.
phagocytophilum antibodies in the serum of cats. Approximately 30% of cats with proven clinical infections induced
by A. phagocytophilum are seronegative when first assessed serologically, but all proven cases to date have
ultimately seroconverted. Some mountain lions with A. phagocytophilum DNA amplified from blood have been serum
antibody negative (Foley et al., 1999), so a single negative antibody result in an acutely infected cat does not exclude
infection. Therefore cats with suspected anaplasmosis may need convalescent serum samples to prove infection.
Alternately, antibody testing could be combined with PCR testing of whole blood in acute cases (Lappin et al., 2004).
Advanced
In a recent study of cats (n = 4) exposed to wild-caught Ixodes scapularis ticks from Rhode Island, all cats developed
antibodies that were detectable in a commercially available kit labelled for use with canine serum (SNAP 4DX,
IDEXX) and became PCR positive (Lappin et al, 2015). However, none of the cats developed measurable clinical
signs of disease or complete blood cell abnormalities. Different A. phagocytophilum peptides can be used to
diagnose recent infection.
Therapy
Supportive care should be administered as needed. Several antibiotics have been administered to naturally
infected cats, but all cats in two studies became clinically normal within 24 to 48 hours after initiation of tetracycline or
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doxycycline administration, and recurrence was not reported (Bjoersdorff et al., 1999; Lappin et al., 2004; Savidge
2015). Although clinically normal, two cats were still PCR positive 17 days and 90 days after treatment (of 21 to 30
days’ duration), respectively, which suggests that treatment with tetracyclines for 21 to 30 days may be inadequate
for eliminating the organism from the body (Lappin et al., 2004).
& Learn
Generalist
Zoonotic Aspects and Prevention

To prevent A. phagocytophilum infection in cats, acaricidal products approved for use on cats should be
used. A. phagocytophilum can likely be transmitted by blood; therefore cats used as blood donors in endemic areas
should be screened for infection by serum antibody tests or PCR assay, and positive cats should be excluded as
Lunch
donors.
References
1. Adaszek Ł, Górna M, Skrzypczak M, et al. Three clinical cases of Anaplasma phagocytophilum infection in
cats in Poland. J Feline Med Surg 2013;15:333-337.
2. Bjoersdorff A, Svendenius L, Owens JH, et al. Feline granulocytic ehrlichiosis; a report of a new clinical entity
and characterization of the new infectious agent. J Sm Anim Pract 1999;40:20.
3. Burgess EC. Experimentally induced infection of cats with Borrelia burgdorferi. Am J Vet Res
1992;553:1507-1511.
4. Chandrashekar R, Mainville CA, Beall MJ, et al. Performance of a commercially available in-clinic ELISA for
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the detection of antibodies against Anaplasma phagocytophilum, Ehrlichia canis, and Borrelia burgdorferi
and Dirofilaria immitis antigen in dogs. Am J Vet Res 2010;71:1443-1450.
5. Foley JE Leutenegger CM, Dumler JS, et al. Evidence for modulated immune response to Anaplasma
phagocytophila sensu lato in cats with FIV-induced immunosuppression. Comp Immunol Microbiol Infect Dis
2003;26:103.
6. Krupka I, Straubinger RK. Lyme borreliosis in dogs and cats: background, diagnosis, treatment and
prevention of infections with Borrelia burgdorferi sensu stricto. Vet Clin North Am Small Anim Pract
2010;40:1103-1119.
7. Lappin MR, Chandrashekar R, Stillman B, Liu J, Mather TN. Evidence of Anaplasma phagocytophilum and
Borrelia burgdorferi infection in cats after exposure to wild-caught adult Ixodes scapularis ticks. J Vet Diag
Invest 2015;27(4):522-5..
8. Lappin MR Breitschwerdt EB, Jensen WA, et al. Molecular and serologic evidence of Anaplasma
phagocytophilum infection in cats in North America. J Am Vet Med Assoc 2004;225:893.
9. Levy SA, O'Connor TP, Hanscom JL, et al. Evaluation of a canine C6 ELISA Lyme disease test for the
determination of the infection status of cats naturally exposed to Borrelia burgdorferi. Vet Ther 2003;4:172-
177.
10. Lewis GE Jr, Huxsoll DL, Ristic M. Experimentally induced infection of dogs, cats, and nonhuman primates
with Ehrlichia equi, etiologic agent of equine ehrlichiosis, J Am Vet Med Assoc 1975;36:85-88.
11. Magnarelli LA, Bushmich SL, IJdo JW, et al. Seroprevalence of antibodies against Borrelia burgdorferi and
Anaplasma phagocytophilum in cats. Am J Vet Res 2005;66:1895-1899.
12. McCall JW, Baker CF, Mather TN, et al. The ability of a topical novel combination of fipronil, amitraz and (S)-
methoprene to protect dogs from Borrelia burgdorferi and Anaplasma phagocytophilum infections transmitted
by Ixodes scapularis. Vet Parasitol 2011;179, 335-342.
13. Quimby JM, Olea-Popelka F, Lappin MR. Comparison of digital rectal and microchip transponder
thermometry in cats. J Am Assoc Lab Anim Sci 2009;48:402-404.
14. Qurollo BA, Balakrishnan N, Cannon CZ, et al. Co-infection with Anaplasma platys, Bartonella henselae,
Bartonella koehlerae and 'Candidatus Mycoplasma haemominutum' in a cat diagnosed with splenic
plasmacytosis and multiple myeloma. J Feline Med Surg. 2014 Jan 20. [Epub ahead of print]
15. Rejmanek D, Freycon P, Bradburd G, et al. Unique strains of Anaplasma phagocytophilum segregate
among diverse questing and non-questing Ixodes tick species in the western United States. Ticks Tick Borne
Dis 2013;4:482-487.
16. Savidge C, Ewing P, Andrews J, Aucoin D, Lappin MR, Moroff S. Anaplasma phagocytophilum infection of
domestic cats: 16 cases from the northeastern USA. J Fel Med Surg 1:7;2015.
Advanced
17. Zhi N, Ohashi N, Tajima T, et al.: 2002, Transcript heterogeneity of the p44 multigene family in a human
granulocytic ehrlichiosis agent transmitted by ticks. Infect Immun 70:1175–1184.
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Feline Dental Radiology Masterclass and Hands-on Lab

Generalist
Importance of Dental Radiology
Dental radiology is quickly becoming the standard of care in feline veterinary dentistry. This is due not only to
the fact that it is crucial for proper patient care, but also because of a significant increase in client expectations.
Finally, providing dental radiographs as a routine service can create significant income for a veterinary practice.
This presentation will cover numerous pathologies for which dental radiographs are indicated. This will prove that
dental radiographs are often critical for proper diagnosis and treatment of oral disease. These conditions should not
be viewed as unusual; they are present within all of our practices. Not radiographing these teeth means leaving
painful/infectious pathology behind.
Utilizing the knowledge gained from dental radiographs will not only improve patient care, it will also increase
acceptance of treatment recommendations. Consequently, will lead to increased numbers of dental procedures
performed at your practice. Finally, the information gained by via the radiographs should help smooth dental
procedures.
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Periodontal disease
Periodontal disease is by far the most common problem in small animal veterinary medicine. It has been
reported that by the age of two, 70% of cats have some form of periodontal disease by just 3 years of age. Therefore,
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the vast majority of veterinary patients have probing depths which are greater than normal.
Periodontal probing is an important first step in the evaluation of periodontal disease. However, there are
several reasons that dental radiographs should be obtained when evaluating periodontal disease.
1. First, periodontal pockets may be missed during probing due to narrow pocket width, a ledge of calculus, or a
tight interproximal space. The latter condition is quite common in the molar teeth; especially in small and toy
breed dogs. Dental radiographs may elucidate these pathologic pockets.
2. Dental radiographs of periodontally diseased teeth can serve as a visual baseline to evaluate the
effectiveness of professional therapy and homecare. This knowledge will help the clinician to decide which
teeth should be treated more aggressively or extracted based on the trend in the level of the alveolar bone.
3. Radiographs are absolutely critical in cases of periodontal disease of the rostral mandible of cats. In this
area, periodontal disease can cause marked weakening of the mandible and significantly increase the
possibility of iatrogenic fracture during the extraction attempt. A pre-operative dental radiograph can help the
practitioner to avoid this disaster. Alternatively, if a mandibular fracture does occur, the radiograph will
provide conclusive evidence as to the cause.
Feline Tooth Resorption (TR)

Dental radiographs are absolutely critical for proper dental care in feline patients. This is because resorptive
lesions, which are very common, require x-rays for diagnostic and therapeutic purposes. Since these lesions
typically initiate at or below the gingival margin, clinical evidence does not appear until fairly late in the disease
course. Therefore, severe root and painful cervical crown resorption often occur undetected for long periods of time.
For this reason, many veterinary dentists recommend full mouth dental radiographs in all feline patients. Recently,
one study revealed that the mandibular third premolars (307 and 407) were typically the first teeth affected. This has
led to the recommendation of starting with dental radiographs of these “sentinel” teeth in asymptomatic feline
patients. If there is no clinical evidence of resorption to any tooth, and no radiographic signs on these teeth, no
further radiographs are warranted. If there is any radiographic resorption to these teeth or clinical evidence of
resorption to any tooth, full mouth radiographs are recommended. However, this author has often noted significant
resorption to only the mandibular canines and thus tends to expose full mouth dental radiographs in all feline
patients.
Advanced
Once a TR lesion is diagnosed, radiographs are critical to making appropriate therapeutic decisions. There
are two recognized types of TRs (1 and 2). Type 2 lesions demonstrate significant replacement resorption of the
roots which makes extraction very difficult. Resorption in these cases typically continues until no recognizable tooth
structure remains. In these cases, endodontic infection does not occur. This finding has resulted in the accepted
therapy of crown amputation for treating these teeth. Remember, ONLY if there is significant ankylosis and root
resorption (no evidence of periodontal ligaments or endodontic system), is crown amputation and intentional root
retention an acceptable method of therapy. In addition, patients with caudal stomatitis should not receive crown
amputation.
In contrast, type 1 TRs do not undergo replacement resorption. These teeth generally retain sufficient normal
root and pulp structure to result in pain and infection. If the dental radiograph reveals intact root structure or worse
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yet an active infection (endodontic or periodontal) then complete extraction of the root is mandated. Extraction of
these teeth often requires a surgical approach to achieve complete removal due to the resorption.
Armed with a diagnostic dental radiograph, the surgeon can save time by directing his or her efforts
appropriately rather than delving after retained/ankylosed roots. Radiographs will also allow the practitioner to more
accurately estimate the surgical time and cost of the procedure.
Generalist
There are no reliable clinical signs that accurately differentiate between type 1 and type 2 lesions. In
addition, the degree of replacement resorption cannot be determined without dental radiographs. Therefore, without
the knowledge provided by dental radiographs crown amputation therapy should NOT be performed.
Endodontic (root canal) Disease

Endodontic disease is also very common in veterinary dentistry. Unfortunately, animal patients with
endodontic disease will typically suffer for a long time prior to diagnosis and definitive treatment. Therefore, the vast
majority of endodontic cases go undiagnosed due to the lack of outward signs of disease other than a broken or
discolored tooth. This is because cats and dogs very rarely show any obvious signs of oral pain or the disease
process.
In cases of obvious endodontic compromise such as a complicated crown fracture or intrinsic staining,
radiographs may sway the reluctant client into allowing therapy. However, dental radiographs are even more critical
in cases where endodontic disease has either subtle or no clinical signs.
The most common instance of camouflaged endodontic disease is an uncomplicated crown fracture, where
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dentin but not the pulp is exposed. In cats this is most common on the maxillary canine teeth. In the majority of
cases, these teeth are vital; however there is a possibility that the endodontic system has been infected through the
dentinal tubules. This can result in tooth non-vitality and infection/abscessation just like a tooth with direct pulp
exposure. This painful infection cannot be diagnosed without dental radiographs. Therefore, every tooth with direct
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dentin exposure should be radiographed to rule out endodontic disease. Further therapy is always indicated,
depending on the results of the dental radiograph. If the dental radiographs reveal no signs of endodontic disease, a
bonded sealant should be performed to seal off the tooth from infection and to decrease sensitivity. The patient
should have dental radiographs repeated in 9 months to ensure the tooth is/was not sub clinically infected. If there is
evidence of tooth death (wide root canals or periapical lucency), root canal therapy or extraction is mandated.
The other scenario of camouflaged endodontic disease are clinically normal teeth, which are actually
infected. It is important to remember that infected rarely present with clinical abscessation, making diagnosis without
dental radiographs impossible. The result is countless patients being chronically affected with painful/infected teeth.
Not only will dental radiographs diagnose the abscess as a dental problem, it will also elucidate which tooth is
causing the infection. These cases (as well as many others) prove the value of full mouth radiographs for all cats
undergoing dental procedures.
Persistent deciduous teeth (previously called retained)

Extraction of persistent deciduous teeth is a very common procedure performed in veterinary dentistry.
However, without dental radiographs this can be a very difficult and frustrating endeavor. If a deciduous tooth
fractures, does it need to be surgically extracted or will it resorb on its own? Unfortunately, without the benefit of
dental radiographs, this question cannot be answered.
In some cases, the root of the deciduous tooth is normal and is held in naturally by the periodontal ligament.
In these cases, extraction is straightforward and root fracture should not occur if the extraction is performed correctly.
In most cases however, the deciduous teeth will have undergone some to significant resorption due to the
pressure placed on the deciduous tooth by the erupting permanent dentition. These teeth may also be resorbing or
ankylosed, but an intact root canal is often still present. The resorption and ankylosis makes extraction very difficult
and will commonly result in a fractured root. In these cases, as in resorptive lesions above, a surgical approach from
the beginning may be prudent. Regardless, if there is an identifiable root canal, these roots require complete
extraction to avoid inflammation and infection.
Finally, there are occasional cases where the root structure of the deciduous tooth has been completely
resorbed and the crown is only being held in by ankylosis at the alveolar crest. Proper therapy for this requires that
only the crown and the very small retaining root segment be removed. By knowing this from the start, the practitioner
saves time by not looking for the root, avoids worrying about a problem that does not exist, and does not cause
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unnecessary trauma to the patient.
Extractions
Pre and post-operative dental radiographs should be exposed for all extraction procedures. Pre-extraction x-
rays allow the practitioner to determine the amount of disease present, any root abnormalities (curved,
supranummary, ankylosis). Fully 10 % of maxillary third premolars in cats have a third root. In addition, the level of
remaining bone will be elucidated (see periodontal disease above). In the case of a mandibular canine extraction,
knowing the amount of remaining mandibular bone can be critical to avoid a pathologic fracture. Finally, the
radiographs will serve as legal evidence of the need for extraction.
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Post-extraction dental radiographs are equally important. Regardless of the appearance of complete
extraction, there is still a possibility of retained roots or other pathology, making post-operative radiographs critical in
all cases. Finally, they will also serve as a legal document in cases of complications.
Conclusion
Generalist
Considering that nearly every veterinary patient has some form of oral disease and that dental radiographs
are indicated for all oral disease, virtually all patients will benefit from the information provided by dental radiographs.
In addition, dental radiographs are a critical piece of information for the veterinarian when treating oral disease.
Therefore, dental x-ray equipment should be used on a daily basis in every general practice.
Dental Radiology Simplified

Dental Radiograph Units
Radiographic exposure is controlled by 3 components: kVp (kilovolt peak), MA (milliamperage), and
exposure time. KVp controls the “quality” of the x-ray beam. This is the power of each particular x-ray particle which
controls the penetration of the beam through tissues.
The quantity of the exposure is controlled by MA and time of exposure. The higher the MA, the more X-rays
produced over the time period. Multiply this number by the exposure time and you will get the total number of x-ray
units.
Since there is not a significant amount of variation of tissues in oral radiology, the KVP and MA are set
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constant on dental radiology units. The only variable factor is time. This is measured in seconds or pulses. One pulse
is equal to 1/60 of a second. Most standard (human) dental radiology units have a digital control for the exposure and
it is set by the operator based on a technique chart. Recently, however, veterinary specific machines have become
available which has a computer that sets the exposure based on the size of the patient, the speed of dental film
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used, and the particular object tooth. This can take a lot of the guesswork out of the exposure setting. However, with
a little experience and practice, it is easy to figure out a setting.
Dental Radiographic Film

Dental film is non-screen film. This means that it is directly exposed by the x-ray and does not require an
intensifying screen. This gives much more detail than standard radiographic film, but requires a higher amount of
exposure. It is packaged in its own paper or plastic sleeve, to protect it from light and the oral environment. There are
two types of dental film commonly used in dental radiology. These are Ultra-speed “D” and Ektaspeed “E” film.
Recently “F” speed film has become popular. The difference is in the size of the silver halide crystals and secondary
to this the amount of exposure required to expose the dental film. “E” speed film requires approximately ½ the
amount of radiation for exposure than “D” speed film, and “F” speed even less. This decreases exposure to the
patient and staff as well as decreases the wear and tear on the x-ray unit. There is a slight decrease in resolution
with faster films due to the larger crystal size, but according to most experts, the difference is negligible. Therefore, it
is recommended in human dentistry to use “E or F” speed to decrease exposure time. They are more technique
sensitive, however, in both the exposure and development of the image. This may be frustrating for the novice,
therefore it is generally recommended that practitioners start with “D” speed and advance to “E or F” speed when
they are more comfortable with the settings and positioning.
There are several different sizes of dental film available (4, 3, 2, 1, and 0). The most common sizes used in
veterinary medicine are 4, 2, and 1. Size 3 are bite wings and are generally not used in veterinary medicine. Size 4
(occlussal) film is the largest available, it is used mostly in large breed dogs or when taking whole mouth
radiographs. For small dogs and cats and most any single tooth radiograph, size 2 (standard) is commonly used. For
the mandibular first and second premolars, and very small cats and puppies size 1 (or 0) (periapical) are used.
Another consideration in selecting film size is cost. Size 4 film is about 3 times the cost of size 2. Therefore, if you
can use a size 2, it is recommended. However, it is much easier to position size 4 films, allowing for much more
latitude in positioning. This will result in less retakes. Therefore, the less experienced may consider practicing with
size 4 film and graduating to size 2 when a level of skill is obtained.
Digital Dental Radiology

There are numerous human veterinary digital systems. These are excellent means of obtaining dental
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radiographs. The only major problem currently is the lack of a number 4 sensor. The major advantages to these
systems are the decrease in radiation exposure, rapidity of the development, and that you can reposition the sensor
if the view is not correct the first time. There is one company, however which makes a size 4 phosphor plate (CR).
Taking a Dental Radiograph

Step 1: Patient Positioning
Position the patient so that the area of interest is convenient to the radiographic beam. In general this is
where the object is “up”. For maxillary teeth, the patient should be in ventral recumbency. For mandibular canines
and incisors the pet should be in dorsal recumbency. Finally, for maxillary cheek teeth, the patient should be in lateral
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recumbency with the affected side up. This being said, in our practice virtually all radiographs are exposed in lateral
recumbancy. This takes some getting used to, but decreases the number of times a patient must be rolled when
doing surgical or endodontic procedures.
Step 2: Film Placement within the Patient’s Mouth

Generalist
There is an embossed dot on the film. The convex side of this should be placed towards the x-ray beam. In
most films, this side is pure white. The oppos ite or “back” side of the film will usually be colored (purple or green).
Place the film in the mouth so that the entire tooth (crown and entire root surface) is covered by the radiograph.
Remember, the roots of all teeth are very long. This is especially true of canine teeth, which are longer than you
think. Always err on the side of having the film too far in the mouth to ensure you do not cut off the root apexes. The
film should be placed as near as possible to the object (generally touching the tooth and gingiva) to minimize
distortion.
Step 3: Positioning the Beam Head

There are two major techniques for positioning the beam head in veterinary patients. Both of these
techniques are used daily in veterinary practice.
Parallel technique: This is where the film is placed parallel to the object being radiographed and
perpendicular to the beam. This is how standard (large) films are taken. This gives the most accurate image.
Unfortunately this is only useful in the lower cheek teeth in the dog and cat. This is due to the fact that these patients
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don’t have an arched palate. The film cannot be placed parallel to the tooth roots because of the palate’s
interference. Therefore this technique is not always possible.
Bisecting Angle Technique: This is the most common type of dental radiograph taken in veterinary patients.
This uses the theory of equilateral triangles to create an image that accurately represents the tooth in question. To
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utilize this technique, the film is placed as parallel as possible to the tooth root. Then the angle between the tooth
root and film is measured. This angle is cut in half (bisected) and the beam placed perpendicular to this angle. This
gives the most accurate representation of the root.
If this angle is incorrect, the radiographic image will be distorted. This is because the x-ray beam will create
an image that is longer or shorter than the object imaged. The best way to visualize this is to think of a building and
the sun. The building will create a 90 degree (right) angle to the ground. The bisecting angle in this case is 45
degrees to the ground.
Early and late in the day, the sun is at an acute angle to the building and casts a long shadow. In radiology
this occurs when the angle of the beam to the object is too small and is known as elongation. At some point in the
late morning and early afternoon, the sun is at a 45 degree angle to the building, which is the bisecting angle. This
gives an accurate representation of the building height. As the sun continues up in the sky, the shadow shortens.
This occurs in veterinary radiology when the angle is too great and is known as foreshortening. Finally, at noon, the
sun is straight up from the building, which gives no shadow.
The “Simplified Technique” as developed by Dr. Tony Woodward does not utilize direct measurement of
any angle, instead relying on approximate angles to create diagnostic images. There are only 3 angles used for all
radiographs in this system 20, 45, and 90.
Mandibular premolars and molars are exposed at a 90 degree angle, maxillary premolars and molars at a
45-degree angle, and incisors and canines at a 20 degree angle.
To initiate any radiograph, place the film in the mouth and set the positioning indication device (PID)
perpendicular to the film. For mandibular cheek teeth, this is the correct placement. For the maxillary premolars and
molars, rotate the beam to a 45 degree angle. For the incisors and mandibular canines rotate 20 degrees. For the
maxillary canines an additional rotation 20 degrees lateral is necessary to avoid superimposition of the first and
second premolars.
Step 4: Setting the Exposure

If you are using a machine where you set the exposure manually, you will need to set up a technique chart
similar to one for a standard (large) unit. The good news is that there is only one variable that needs to be adjusted.
If you are utilizing the computer controlled system, set the buttons for the species, size of the patient, and
tooth to be imaged. If you have correctly set the machine and the image is incorrectly exposed, the easiest way to
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adjust is to change the f setting. By pressing this button, you will see the numbers go up on both sides. The one on
the left is the f number and the one on the right is the exposure time. If you continue to press the button it will
continue to increase the exposure until you reach 9 when it will markedly lower and the f number will go back to 1. If
the radiograph is overexposed (too dark) lower the f number by 1. If it is underexposed (too light) increase the
number by 1. Continue this process until you have the film that you want. Generally, the f number will be the same for
all radiographs once you have discovered the correct setting for your machine start at that number in future sessions.
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Step 5: Exposing the Radiograph
Dental radiograph machines have a hand held switch to expose the radiograph. If it is possible, leave the
room prior to exposing the radiograph. If it is not, stand at least 6 feet away at a 90 to 130 degree angle to the
primary beam (meaning to the side or back of the tube head, not in front or behind). Once everything is set, press the
button. It is important to remember, that these switches are “dead man’s”. This means if you let up during the
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exposure, it will stop the production of x-ray beams. On a standard unit, this will make a light radiograph, on a
computer controlled one it will give an error message and you will need to start over. Make sure you hold the button
down until the machine stops beeping.
Step 6: Developing the Radiograph

The most economical way to develop the radiograph is coffee cups filled with dental developing solutions in
your darkroom. (Using chemicals other than products for dental radiology will result in inferior film quality)
Although developing films in a darkroom can produce quality films, the use of a chair side developer has several
distinct advantages.
1. The chair side developer also allows you to easily judge when development time is correct, and be able to
evaluate your films in only 1-2 minutes.
2. The technician does not leave the room and can still monitor the patient.
3. The units take up very little space, minimize chemistry use, clean up easily and store quickly.
Para-professional
To develop films, begin by peeling back the covering layers from the film, taking care to handle the film only
by the edges. Use a film clip to grasp the corner of the film and place it in the developer. When developing a size 4
film, make sure to immerse the entire film in the liquid to ensure that the whole film gets developed. Develop the film
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until an image is just visible (sight developing). Then rinse the film briefly in a water bath, and place the film in the
fixer for one minute until partially fixed. The film may be evaluated at this time, but should be placed back in the fixer
for an additional 10 minutes to ensure complete fixation (archival quality). When completely fixed, the film becomes
clear and will lose all traces of a greenish color. The film should then be thoroughly rinsed in running water or placed
in a clean water bath for 10-15 minutes. This is followed by a final rinse to remove all traces of fixer. Be sure to
remove the clip and rinse all film surfaces thoroughly. Traces of fixer remaining on a dental film give it a characteristic
“slick” feel, therefore rinse the film under running water while gently rubbing the film between your fingers, for a few
seconds, until the film does not feel slick. The film is then placed in drying clips overnight to dry. Make sure to dry the
film completely to ensure that they do not stick together.
Be sure to change the solutions whenever the developing and fixation times seem to be slowing down. This
will occur after you have developed and fixed around 20 smaller (#0 or #2) films, or 10-15 larger (#4) films. Use of
exhausted chemistry results in poor image quality and hazy images.
Dental Radiograph Interpretation

Interpreting dental radiographs can be daunting, but it is very similar to interpreting a standard boney
radiograph. The major difference is that dental radiographic changes are often more subtle. In addition, there are
pathologic states that are unique to the oral cavity. Finally, there are several normal anatomic structures that may
mimic pathologic changes.
This lecture concentrates on the most common pathologies, which are illustrated by classic examples. Note
that in practice, these lesions are often less obvious. The reader is directed to additional continuing education
meetings to further their expertise. In addition, vetdentalrad.com is an excellent resource for questionable cases.
Determining Which Teeth were Imaged

The first step in radiographic interpretation is determining which teeth have been imaged. This requires not a
firm knowledge of oral anatomy as well as the architecture of dental films. Digital systems with veterinary templates
do not require this step as long as the images are properly placed (DO NOT ASSUME THIS WAS DONE
CORRECTLY). If your system does not support a veterinary template, there is a mark on the image which is in a
consistent location. Review the owner’s manual for instructions on its use.
The key to properly identifying the imaged teeth is the embossed dot, which is on one corner of the film.
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When exposing a radiograph, if the film is properly positioned, the convex surface will point towards the radiographic
tube head. There is no way to expose a diagnostic radiograph with the film in backwards, due to the lead sheet on
the back side of the film. Therefore, when interpreting the film, the embossed dot is facing out of the mouth.
First, place the dot towards you (this is done for you on most digital systems). This means you are looking at the
teeth as if you are the beam.
Next, rotate the film so that the roots are in their natural position (up on maxillary and down on mandibular).
Canines and incisors: This orients the film so the right side of the mouth is on the left, and right side is on the left.
This is like a VD abdomen radiograph.
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Molars and Premolars: Ascertain mesial from distal. If the mesial side is on the left side of the film, it is a
radiograph of the left side of the patient and vice versa for the right.
Normal Radiographic Anatomy

There are numerous structures within the oral cavity that mimic pathologic states depending on the
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projection. Knowledge of normal radiographic anatomy will help avoid over interpretation.
Normal alveolar bone will appear gray and relatively uniform throughout the arcade. It is slightly more
radiopaque “darker” than tooth roots. In addition, it appears slightly but regularly mottled. Alveolar bone should
completely fill the area between the roots (furcation) and end at the cementoenamel junction (CEJ). The root canals
should all be the same width; allowing for differences in the diameters of the root. There should be no radiolucent
areas in teeth or bone. A regular thin dark line (periodontal ligament) should be visualized around the roots.
There are several normal anatomic findings that are commonly misinterpreted in dental images as
pathologic. On radiographs of the mandibular cheek teeth, a thick, horizontal radiolucent line courses parallel to and
just coronal to the ventral cortex of the mandible. This is the mandibular canal. In addition, there are three circular
radiolucent areas seen in the area of the apices of the first three premolars, which are the mental foramina (rostral,
middle, and caudal). On rostral mandibular views, a radiolucent line will be present between the central incisors.
This is the fibrocartelagenous mandibular symphysis. In the rostral maxillary area: there are paired radiolucent areas
distal to the intermediate incisors, which are the palatine fissuresAny questionable areas should be evaluated by
exposing a comparative view.
Para-professional
A suspicious periapical lucency (especially in the area of the mandibular premolars) should be evaluated with
an additional film exposed at a slightly different angle (in the horizontal or vertical plane). If the lucency is still
centered on the apex, it is likely real. If the lesion moves off the apex or disappears, it is an artifact. Suspect changes
in the diameter of the root canal of a tooth should be compared against surrounding as well as contralateral teeth.
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Surrounding teeth can be seen on the same film with the “lesion”. The contralateral view should be taken at the same
angle as the original. It is important to note that root canals are not exact cylinders (especially canines). A lateral view
may have a much different canal width than a V/D view.
Periodontal Disease
Periodontal bone loss results from the combination of bacterial induced inflammation and host response
creating osteoclastic resorption of bone. This resorption will result in crestal bone loss to a level below the
cementoenamel junction. This decrease in bone height may also create furcational exposure. Horizontal bone loss is
the most common pattern in veterinary patients is horizontal. This appears as generalized bone loss of a similar level
across all or part of an arcade. The other pattern is angular (vertical) bone loss. The radiographic appearance of
angular bone loss is one area of recession below the surrounding bone. The surrounding bone may be normal or be
undergoing horizontal bone loss. Therefore it is common to have a combination of the two types in the same arcade.
Bone loss does not become radiographically evident until 30-50% of the mineralization is lost. Therefore,
radiographic findings will always underestimate bone loss. In addition, bone loss on only on surface (i.e. lingual,
palatal, or facial) may be hidden by superimposition of bone or tooth. This may resulting in a non-diagnosed bony
pocket. Always interpret radiographs in light of the complete oral examination findings.
Endodontic Disease
Endodontic disease may be demonstrated radiographically in several ways. An individual tooth may have
one, some, or all of the different changes listed below. However, only one need be present to establish a
presumptive diagnosis of endodontic disease. Radiographic changes can be broken into two major classifications: 1)
changes in the surrounding bone, or 2) changes within the tooth itself.
Bony Changes
The classic and most obvious finding is periradicular rarefaction. This appears as a radiolucent area
surrounding the apex of a root. On rare occasions, this may also be seen mid-root, but these will virtually always be
associated with periapical disease. Other, more subtle changes include a widened periodontal ligament, a thickened
or discontinuous lamina dura, or even periradicular opacities. It is important to be aware of superimposed lucencies
which are artifactual. These structures (i.e. mental foramina) can be imaged over an apex and falsely appear as
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osseous rarefaction. There are several clues that superimposed lucencies are artifactual. First, superimposed
artifacts are typically seen on only one root, whereas it is very rare to find a true periapical lesion on only one root of
a multi-rooted tooth. In addition, artifacts tend to be regular in appearance, whereas true periapical lesions are
ragged.
If any area is in question, it is best to expose an additional film with a slightly different angle. If a periradicular
lucency is still centered over the apex, it is likely real and not an artifact.
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Tooth Changes
The most common change in endodontic disease within the tooth itself is a root canal with a different
diameter. As a tooth matures, secondary dentin production will cause a decrease in canal width. When a tooth
becomes non-vital, this development stops secondary to the death of the odontoblasts. Consequently, non-vital teeth
have wider root canals than the surrounding vital teeth. Conversely, on rare occasions, pulpitis may result in
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increased dentin production, and create an endodontically diseased tooth with a smaller root canal. This is especially
common in teeth that are also periodontally diseased. This could potentially lead to a misdiagnosis of the
endodontically diseased tooth as healthy and vice versa with the contralateral tooth. Hence it is important to evaluate
the adjacent teeth as well as the contralateral.
Width discrepancy can be compared to any tooth (taking the size of tooth into consideration) but it is most
accurate is to compare to the contralateral tooth.
Endodontic disease may also be manifested radiographically as internal resorption. This results from
osteoclastic activity within the root canal system due to pulpitis. These changes create an irregular, enlarged region
within an area of the root canal system. Finally, external root resorption can be seen with endodontic disease. It will
appear as a defect of the external surface of the root, generally accompanied by a loss of bone in the area. External
resorption most commonly occurs at the apex in companion animals and is quite common in cats with chronic
endodontic disease.
Feline Tooth Resorption (TR’s)
Para-professional
TRs are the result of odontoclastic destruction of feline teeth, and are classified as either type 1 or type 2. In
type 1 there is no replacement by bone, whereas in type 2 there is replacement of the lost root structure by bone.
TRs are very common in our feline patients. Studies have reported up to a 70% incidence in felines over 6 years of
age! The etiology at this point is unknown. They are not bacterial in nature, although in some cases the inflammation
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which activated the odontoclasts may have been bacterial in nature. There are numerous theories; however none
have been proven at this time. Osteoclastic resorption will generally begin at the cervical line of the tooth and
progress at varying rates until in some cases no identifiable tooth remains.
Type 1 TRs are typically associated with inflammation such as gingivostomatitis or periodontal disease.
Thus, they are commonly associated with periodontal bone loss on dental radiographs. In these cases, it is believed
that the soft tissue inflammation activated the osteoclasts. The teeth will have normal root density in some areas and
a well-defined periodontal space. In addition, there is often a definable root canal in the intact part of the tooth. This
type will have significant resorption of the teeth and tooth roots that are not replaced by bone.
Type 2 TRs are usually associated with only localized gingivitis on oral exam, in contrast to the more severe
inflammation due to periodontal disease or gingivostomatitis seen with type 1. In these cases, the gingival
inflammation is secondary to the TR. The radiographic appearance is that of teeth which have a different
radiographic density as compared to normal teeth, as they have undergone significant replacement resorption.
Findings will include areas with no discernable periodontal ligament space (dentoalveolar ankylosis) or root canal. In
the late stages, there will be little to no discernable root structure (ghost roots). In these cases, the lost root structure
will be replaced by bone.
The importance of dental radiography in TR cases cannot be overstated. Type 1 lesions typically retain a
viable root canal system, and will result in pain and endodontic infection if the roots are not completely extracted.
However, the concurrent presence of a normal periodontal ligament makes these extractions routine. With type 2
lesions, there are areas lacking a normal periodontal ligament (ankylosis) which also demonstrate varying degrees of
root resorption, which makes extraction by conventional elevation difficult to impossible. The continued resorption in
type 2 teeth is the basis for crown amputation therapy. It is this author’s opinion that teeth with an identifiable root
canal on dental radiographs MUST be extracted completely, while teeth with no discernable root canal may be
treated with crown amputation. If there is any question, always err on the side of complete extraction.
Neoplasia
Neoplasia is defined as the abnormal growth of cells that is not responsive to normal growth control.
Neoplasms can be further classified by their biologic behavior as benign or malignant.
Benign Masses
Advanced
Most benign neoplastic growths will have no boney involvement on dental radiographs. If bone involvement
does occur with a benign growth it will be expansive, resulting in the bone “pulling away” from the advancing tumor
leaving a decalcified soft tissue filled space in the tumor site. Bony margins are usually distinct. Finally, this
expansive growth will typically result in tooth movement.
Cysts
Cystic structures will appear as a radiolucent area with smooth bony edges. Similar to other benign growths,
they grow by expansion and thus displace the other structures (eg teeth). Dentigerous cysts are typically seen as a
radiolucent structure centered on the crown of an unerupted tooth.
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Malignant Neoplasia
Malignant oral neoplasms typically invade bone early in the course of disease, resulting in irregular, ragged
bone destruction. Initially, the bone will have a mottled “moth eaten” appearance, but radiographs late in the disease
course will reveal a complete loss of bone (the teeth will appear to float in space). If the cortex is involved, an
irregular periosteal reaction will be seen.
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Histopathologic testing is always necessary for accurate diagnosis of oral masses since a variety of benign
or malignant tumors appear radiographically similar. In addition, osteomylitis can create the same radiographic
findings as malignant tumors. Finally, aggressive tumors will show no bone involvement early in the course of
disease. The prudent practitioner will note the type and extent of bony involvement (if any) on the histopathology
request form (and may include copies of the radiographs and pictures) to aid the pathologist. It is key to interpret the
histopathology result in light of the radiographic findings. A diagnosis of a malignancy without bony involvement
should be questioned prior to initiating definitive therapy such as aggressive surgery, radiation therapy, or
chemotherapy. Conversely, a benign tumor diagnosis with significant bony reaction should be further investigated
prior to assuming that the patient is safe.
Additional diagnostic tests in questionable cases include complete blood panel, urinalysis, bacterial and/or
fungal culture, as well as fungal serology.
Retained Tooth Roots

Persistent tooth roots following extraction attempts are a common occurrence in veterinary medicine. In the
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vast majority of cases, there are no outward clinical signs, however the patient suffers regardless. In rare cases, the
retained root may abscess, resulting in significant morbidity to the patient and possible legal action from the client.
Dental radiographs must be exposed following all extractions. Regardless of the appearance of complete extraction,
there is still a possibility of retained roots or other pathology. Therefore, post-operative radiographs are critical in all
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cases. In addition, they will serve as a legal document in cases of complications.
References
1. Niemiec BA: Dental, Oral, and Maxillofacial Disease--A Color Handbook, Manson Publishing Ltd, London
2010
2. Dental radiology simplified educational poster and DVD. vetdentalrad.com
3. Importance of dental radiographs, client educational poster. www.vetdentalrad.com
NOTES:
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2015
3 WORLD FELINE
rd
VETERINARY
Generalist
CONFERENCE SUNDAY, OCTOBER 4, 2015
TRACK A TRACK B

Included in your registration 7:30 – 8:30 am
ABVP Breakfast for Diplomates in Cortez A
Secrets to Improve Quality-of-Life for Chemotherapy Drugs

Cats with Cancer Dr. Erika Krick Sponsored by 8:30 – 9:20 am
Dr. Greg Oglivie
Para-professional
Care Beyond a Cure: Diagnostic Secrets & Less Common Cat Cancers
the Cancer Patient Dr. Erika Krick 9:25 – 10:15 am
Dr. Greg Oglivie
NETWORKING REFRESHMENT BREAK in Exhibit Hall 10:15 – 10:45 am

Injection Site Associated & Other Soft Tissue Top Oncology Mistakes & How to Avoid
Sarcomas: New Advances for 2015 Them: Part 1 10:45 – 11:35 am
10 Best Kept Secrets for Treating Cats Top Oncology Mistakes & How to Avoid
with Cancer Them: Part 2 11:40 – 12:30 pm


12:30 – 1:45 pm
Diarrhea Dilemma: What We Think We Know
About Treatment of IBD, Dr. Susan Little - Hillcrest A
Kitty Oncologic Emergencies: HELP!!! See Something, Do Something. Why wait?

Dr. Greg Oglivie Aspirate.TM 1:45 – 2:35 pm
Dr. Sue Ettinger
The Secret Weapon: Polyunsaturated Practical Take-home Tips for Managing

Fatty Acids & Cancer: Advances for 2015 Feline Cancer Patients in Your Practice 2:40 – 3:30 pm
Conclusion of Conference 3:30 pm

Advanced
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Secrets to Improve Quality-of-Life for Cats with Cancer

Greg Ogilvie, DVM, DACVIM, ECVIM-CA Oncology
Introduction
Cats are elusive and secretive. This makes it a challenge to enhance and improve their quality of life as it is
often difficult to know when they are in need. Regardless, it is our duty to unleash treatments that can ensure they do
well. I call it, following the commandments of kitty care: Don’t let them hurt. Don’t let them have nausea or diarrhea.
Don’t let them starve. The following is divided into three sections to help guide the reader to some secrets of kitty
care.
The First Commandment: Don’t Let Them Hurt!

Compassionate care is the watchword of feline oncology, and pain control is the cornerstone of the caring
process. Sadly, pain control in cats has sometimes been ignored and is only recently being investigated seriously.
Feline pain management can be difficult; cats tend to be secretive, which precludes identifying pain early when it is
easiest to treat. The key to compassionate pain control is timely intervention with analgesics, optimally before pain
receptors ever identify discomfort. A key resource for all feline practitioners is the AAFP guidelines for Pain Relief in
Dogs and Cats.
Mechanisms of Cancer Pain

The most common mechanism of cancer pain is associated with tumor invasion and subsequent tissue
1–6
damage that causes activation of pain receptors. Some forms of therapy can induce pain as well. For example,
surgery and radiation therapy may ultimately relieve pain and suffering but can cause significant short-term
discomfort from tissue and nerve damage. Similarly, although chemotherapy can help control the underlying
malignant process, these drugs can cause discomfort. Vincristine and vinblastine have caused painful
polyneuropathy in a small number of human cancer patients. This adverse effect is suspected to occur in a very
small number of cats and can decrease the patient’s quality of life.
While very little is known about feline pain, a basic understanding of the types of discomfort may help
increase awareness of how cats with cancer can be managed compassionately. The types of pain associated with
1–6
cancer include visceral pain, inflammatory and somatic pain, neuritis, and neuropathic pain.
Visceral Pain
Humans describe this type of pain as a dull, deep, constant, aching pain. Visceral pain is poorly defined;
humans with significant visceral pain often respond best to narcotic and/or nonnarcotic analgesics. It is suspected
that this type of pain results in decreased activity, anorexia, and behavioral changes in cats.
Track A
Inflammatory and Somatic Pain
Frequently described in human medicine but rarely in feline medicine, this pain is well localized, constant,
6
and aching. Common sources of this type of pain include bone metastasis, tissue damage, and musculoskeletal,
dental, and integumental pain. Cats may lick or bite at an area or may exhibit signs of discomfort in subtle ways, such
as by decreasing their activity or limping (if an extremity is affected).
Neuritic Pain
Inflammation of nerves or nerve roots causes neuritic pain and can present as part of a paraneoplastic
syndrome or as a direct effect of tumor compression. Humans describe it as a constant, dull, aching pain that may
have periods of burning “shock-like” sensations. In cats, these shock-like sensations can result in sudden,
unexplained behavioral changes, such as aggression or scratching and biting at an area, often to the point of self-
mutilation.
Neuropathic Pain
This type of pain occurs when a segment of the nervous system that normally transmits pain stimuli is
damaged. It arises from metabolic, immunologic, or direct physical effects on the nervous system. Neuropathic pain
is difficult to control with standard analgesics.
Recognizing Pain
Cats instinctively hide most outward and measurable manifestations of pain and rarely exhibit signs until
discomfort is quite advanced. Indeed, the only clinical indicator of pain and discomfort may be increased systolic
blood pressure. Experienced practitioners and caregivers watch for subtle changes in activity level, appetite, and
movement. Vocalization, while not a specific indicator of pain, is noted in some cats, especially when discomfort is
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significant. Some cats become more reclusive whereas others, especially younger animals, pace and may thrash
around. Tachypnea, tachycardia, and dilated pupils can be used to assess pain in cats, even when they are
stuporous.
The best feline practitioners anticipate and intervene early rather than waiting for clinical signs associated
with discomfort. Caregivers need to be aware of which procedures are likely to cause discomfort, and preemptive
analgesia should be practiced when possible.
1–6
Comprehensive management of pain involves careful evaluation and treatment of each cat. To maximize
quality of life, response to therapy, and survival time for feline patients, adequate pain control must be the highest
goal for the veterinary practitioner. Pain control in feline medicine has only recently come to the forefront of attention,
primarily because of the inappropriate attitudes of clinicians, lack of knowledge about analgesic medications, and
2,3
lack of skill in assessing pain and appropriate therapeutic methods. In many cases, analgesics have been withheld
because of fear of associated adverse side effects and because research demonstrating the beneficial effects of pain
relief in cats is scanty. Client demand has been an important force in bringing pain control to the forefront of
compassionate care. Despite our lack of understanding, we must respond to our patients’ needs and our clients’
concerns by making pain relief and compassionate care a priority.
General Concepts of Pain Therapy

Recent research has demonstrated that once pain is elicited, the pain response is magnified. Preventative
therapy is therefore preferable to suppression of established pain. Premeditated, judicious use of analgesics is likely
to increase cat comfort, decrease the need for hospitalization (and the associated costs), and reduce the amount of
3,6
pain medication needed to achieve the same level of comfort.
The management of pain begins with high-quality, compassionate care by every member of the veterinary
health care team. Careful nursing, gentle handling, and provision of a comfortable and relaxing environment are of
great benefit to cats. Local anesthesia should be employed to alleviate discomfort, and systemic analgesia should be
used when local analgesia may be insufficient. The AAFP/AAHA 2015 Guidelines recommend the PLATTER
approach to pain management:
o Plan Every case should start with a patient-specific pain assessment and treatment plan
o Anticipate The patient’s pain management needs should be anticipated whenever possible so that either
preventive analgesia can be provided or, in the case of pre-existing pain, it can be treated as soon as
possible
o Treat Appropriate treatment should be provided that is commensurate with the type, severity and duration of
pain that is expected
o Evaluate The efficacy and appropriateness of treatment should be evaluated; in many cases, using either a
client questionnaire or an in-clinic scoring system
o Return Arguably the most important step, this action takes us back to the patient – where the treatment is
either modified or discontinued based on an evaluation of the patient’s response
General Approach to Pain Management

Track A
a
Degree of Pain Clinical Approach
b
Mild NSAIDs ± acupuncture
Mild-Moderate NSAIDs ± acupuncture + opioids
Moderate NSAIDs ± acupuncture + opioids (dose escalation) ± anxiolytics
Moderate-Severe NSAIDs ± acupuncture + opioids (dose escalation, different route of
administration) ± anxiolytics
Severe NSAIDs ± acupuncture + opioids (dose escalation, different route of
administration) ± anxiolytics + other palliative procedures (e.g., radiation,
surgery)
a
o Treat the underlying disease.
o Use with caution in patients with renal disease.
1,3,6
Mild Pain
The treatment of mild pain must begin with general compassionate care that includes a comfortable
environment, appropriate bedding, and effective bandaging if indicated. Social cats will respond well to petting and
talking. This is often followed with regular doses of one of the following:
o Nonsteroidal antiinflammatory drugs (NSAIDs) such as aspirin, piroxicam, or ketoprofen, provided renal
function is normal and there is no evidence of gastric inflammation
o Local nerve blocks or acupuncture
o α2-Adrenergic agonists such as xylazine or medetomidine
o Opioid agonists such as morphine, oxymorphone, or fentanyl
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o Opioid agonist-antagonists such as butorphanol or buprenorphine
These agents are generally given individually, and NSAIDs are usually administered first. The NSAIDs
robenacoxib, carprofen and meloxicam are widely used in cats in Europe long term. They are used in cats the USA
for short term indications. Meloxicam has a black box label limiting its use. If NSAIDs are ineffective, an agent from
one of the other categories is selected based on what works best in that patient. Only oral NSAIDS and oral
butorphanol are commonly given at home.
Moderate and Severe Pain

Moderate and severe pain can be treated with compassionate care, local analgesia when possible (including
acupuncture), or NSAIDs (e.g., robenacoxib, carprofen and meloxicam) in judicious combination with drugs from one
of the following categories:
o α2-Adrenergic agonists
o Opioid agonists
o Opioid agonist-antagonists
When drugs are combined, additive toxicity must be monitored. As much as possible, therapy for the
malignancy itself must be a high priority. For example, radiation therapy at sites of bone pain may be profoundly
beneficial. In addition, using another route of administration for analgesics (e.g., switching from subcutaneous to
intravenous administration) may be effective. In some cases, sustained-release fentanyl patches, which are applied
to the skin and slowly release the analgesic over 72 hours, may be helpful.
Nonsteroidal Antiinflammatory Agents

Phenylbutazone, acetaminophen, and ibuprofen are generally not used in cats because of the potential for
severe toxicity.
Aspirin
Aspirin can be used with extreme caution at 10 mg/kg PO q48–72h. Aspirin has a variable duration of action
and is indicated for mild somatic pain and inflammation. Serum half-life is much longer in cats because they lack
adequate glucuronyl transferase for hepatic metabolism of salicylates. Because of the recent availability of safer
NSAIDS, aspirin is rarely used for the treatment of pain in cats.
Ketoprofen
Ketoprofen is a relatively new NSAID. A single postsurgical dose (1 to 2 mg/kg IV, IM, or SQ) can be given.
Gastric ulceration and renal tubular damage are possible, albeit rare, adverse effects.
Piroxicam
Piroxicam is a relatively new and potent NSAID and is probably more effective than ketoprofen. The most
common adverse effects associated with piroxicam therapy include gastric ulceration and renal tubular damage. The
dose for cats is 0.3 mg/kg daily for 4 days and 0.3 mg/kg every other day thereafter. Piroxicam is best dispensed by
compounding the drug in a tasty, flavored base (e.g., fish) and administering as an oral liquid.
Track A
Robenacoxib
Robenacoxib is a COX-2 selective NSAID approved for surgical pain in cats in many countries. It has not
been studied for either feline chronic pain disease or in older cats but there are long-term safety data in young cats
(ie, 5 x the recommended dosage for 6 months and 10 x the recommended dosage for 6 weeks).
Meloxicam
Low-dose meloxicam (ie, 0.01–0.03 mg/kg orally q24h) is effective, easy to administer and is quite palatable
when treating chronic pain in cats and is well tolerated, even in cats with CKD provided their clinical status is stable.
The drug is approved for long term use at 0.05 mg/kg q24h in Europe, Australasia and many other countries. The
oral route of administration and long-term use of meloxicam in cats remain off-label in the USA. Robenacoxib is a
CoX-2 selective NSAiD approved for surgical pain in cats. it has not been studied for either feline DJD or in older cats
but there are long-term safety data in young cats (ie, 5 x the recommended dosage for 6 months and 10 x the
recommended dosage for 6 weeks).147,148
Local Anesthetics
Local anesthetics and analgesics are effective for temporary relief of mild to moderate pain. Lidocaine and
bupivacaine are used most commonly and can be administered locally, within a cavity (e.g., chest cavity), or
epidurally.
Local Administration
Local anesthetics, such as 2% lidocaine HCl, are administered to effect near an incision and provide regional
analgesia for about 1 hour. Bupivacaine HCl (0.75%) can be given to effect to provide 6 to 10 hours of regional
195
analgesia for peri-incisional pain. Lidocaine can be administered at or near intercostal nerves proximal to a
thoracotomy incision to reduce postsurgical pain. This agent is also frequently administered into the pleural cavity
prior to bupivacaine administration to decrease discomfort associated with thoracotomy. Lidocaine or bupivacaine
can be used as a maxillary or mandibular nerve block for oral surgery.
Epidural Administration
Hindlimb pain can be controlled by epidural administration of preservative-free 2% lidocaine (0.5 ml/kg) or
0.75% bupivacaine HCl (1 mg/4.5 kg); duration of anesthesia is 60 to 90 minutes with lidocaine and 4 to 6 hours with
bupivacaine. Fentanyl (4 µg/kg) or medetomidine (10 µg/kg) in 1 ml saline can be injected epidurally for analgesia of
the hindlimb (both drugs) or forelimb (medetomidine only). Fentanyl is much less toxic than medetomidine when used
in this manner.
Opioid Agonists
Morphine
Morphine is a natural opioid agonist. On rare occasions, it may produce initial excitement manifested by
panting, salivation, nausea, vomiting, urination, defecation, and hypotension when administered to cats. These
reactions arise from activation of the chemoreceptor trigger zone, vagal stimulation, and histamine release. Initial
excitement may be followed by central nervous system (CNS) depression, constipation, urine retention, bradycardia,
respiratory depression, and hypothermia. Cats are more resistant than dogs are to stimulation of the chemoreceptor
trigger zone. Analgesia and CNS depression are noted in cats when morphine doses of 0.1 to 0.5 mg/kg every 2 to 6
2,3,6
hours are used ; doses approaching 1 mg/kg can induce marked hyperexcitability, aggression, and stimulation of
the chemoreceptor trigger zone.
Meperidine
At a dose of 2.0 to 5.0 mg/kg IM or SQ, meperidine results in sedation and analgesia, but the effects last only
1 hour in cats.
Oxymorphone
Oxymorphone is a semisynthetic opioid agonist with analgesic properties that are approximately 10 times
more potent than those of morphine; its adverse effects on the respiratory, cardiovascular, and gastrointestinal
systems are less pronounced. Oxymorphone (0.05 to 0.2 mg/kg SQ or IM) lasts 2 to 5 hours and is indicated for
moderate to severe visceral or somatic pain. Lower doses are used for IV administration. When used alone,
2,3,6
however, oxymorphone may result in excitement or hyperalgesia. Diazepam (0.1 to 0.2 mg/kg IV or IM) given
concurrently with oxymorphone may help reduce these side effects.
Fentanyl
Fentanyl is an effective analgesic that can be given IM, SQ, or IV as a preanesthetic. It can be administered
via an IV bolus (0.2 to 50 µg/kg q2–6h), constant rate infusion (1 to 4 µg/kg/hr), or transdermal patch. Fentanyl can
Track A
cause respiratory depression, bradycardia, and somnolence at higher dosages. It can also prolong return to normal
body temperature during recovery from anesthesia.
Fentanyl-impregnated transdermal patches reliably release a controlled amount of fentanyl over a 72 hour
period; depending on the severity of the discomfort, 2.5 mg (25 µg) patches are adequate for treating a 4 to 5 kg cat.
The patches maintain adequate blood levels of fentanyl for 72 hours, but therapeutic levels are not attained for 12 to
24 hours; thus patches may be most effective when used in conjunction with other analgesics or in addition to
constant rate fentanyl infusion during surgery or other painful procedures
Opioid Agonist-Antagonists
Butorphanol
Butorphanol is a synthetic opioid agonist-antagonist that has five times the analgesic potency of morphine
and a duration of analgesia of approximately 1 to 4 hours. Adverse effects such as nausea and vomiting are rare, but
the drug can induce sedation in cats. At 0.1 to 0.4 mg/kg IV, IM, or SQ, butorphanol provides 1 to 4 hours of visceral
analgesia; a higher dose (0.8 mg/kg IV) is needed for somatic pain, and analgesia lasts only about 2 hours. IV
2,3,6
butorphanol may result in transient hypotension or bradycardia. Butorphanol possesses antagonist properties and
reverses the effects of narcotics. Therefore, butorphanol must not be given within 12 hours of any pre- or
intraoperatively administered narcotics.
Buprenorphine
Buprenorphine HCl, an agonist-antagonist, can reverse opioid-induced respiratory depression while
maintaining analgesia. Buprenorphine can be given at 0.005 to 0.01 mg/kg IV, IM, or SQ and lasts 4 to 12 hours. It is
currently available for long term, sustained release formulations. The FDA has more recently approved a
concentrated injectable buprenorphine product for cats (Simbadol; Abbott), which has been formulated to provide a
196
24 h duration of action when administered as directed. Another company, Aratana is exploring a different, but similar
product.
Acupuncture
Acupuncture is the ancient art of inducing a physiologic effect, in this case analgesia, in response to the
insertion of a needle into a specific point along a meridian of the body. This analgesic method has been used for
centuries and has been proven in humans via well-controlled clinical studies. The exact mechanism of action is not
completely understood, but the procedure works in part by releasing endorphins and enkephalins. Acupressure
produces similar results by applying physical pressure to specific areas.
Tranquilizers and Anxiolytics

In some cases, a cat’s anxiety may preclude adequate pain management. Therapeutic trials of tranquilizers
(e.g., acepromazine, diazepam, medetomidine, ketamine, xylazine) to relax the patient may be of substantial benefit.
Xylazine can be used as an anxiolytic (0.05 to 0.2 mg/kg IV or IM) or sedative (0.5 to 2 mg/kg IV, IM, or SQ) to
provide 15 to 30 minutes of relief from visceral pain. At the very low dose of 0.5 to 1.0 mg/kg IM, ketamine relieves
anxiety for 30 minutes; at higher doses (1.0 to 4.0 mg/kg IV) the agent lasts approximately 30 minutes and is helpful
for short painful procedures, such as wound and burn care. It may also be indicated during surgical procedures (e.g.,
amputation of tumor-associated fractures) or radiation therapy at sites of bone pain due to a malignant disease.
Ketamine does not depend on renal excretion and thus can be used safely in cats with diminished renal function.
The Second Commandment: Don’t Let Them Have Nausea or Diarrhea!

Nausea and vomiting can occur for many reasons, such as a mass effect from the primary or metastatic
1–3
tumor or a secondary consequence of the cancer or treatment. Nausea and vomiting may reduce a patient’s
quality of life by inducing such life-threatening problems as dehydration, anorexia, metabolic imbalance, and wound
1–5
dehiscence due to increased abdominal pressure. In addition, caregivers often get the impression that their pet is
experiencing unnecessary toxicities, which may result in abandonment of life-saving treatment and lead to
subsequent euthanasia.
In cats, anorexia or hypersalivation is more common than overt vomiting. Management of nausea and
vomiting is important to improve the quality of life for the cat and can subsequently enhance response to therapy and
increase survival time. Indeed, treatment of nausea and vomiting is part of the overall goal of providing
compassionate care. If the underlying cause of the nausea and vomiting cannot be corrected immediately, nausea
and vomiting should be relieved as soon as they occur.
Many veterinarians find that encouraging caregivers to be part of the health care team helps improve the
patient’s quality of life. Clients should be educated that nausea and vomiting may be preventable When therapy with
the potential to induce nausea/vomiting is initiated, preventative antiemetic therapy (e.g., metoclopramide) must also
be administered. If this is not possible, caregivers should be instructed to start giving oral antiemetics at home as
soon as signs as subtle as anorexia are noted. Similarly, if a cat vomits after receiving chemotherapy, it should be
treated prophylactically during subsequent rounds of therapy until the attending clinician is confident that nausea and
Track A
vomiting are no longer major risks for that patient.
Mechanism of Nausea and Vomiting

The presence of a tumor can lead to problems (e.g., physical obstruction of the intestinal tract) that may
induce nausea and vomiting. In this example, surgical resection of the tumor is the only solution for the underlying
clinical problem. Unlike humans, cats rarely exhibit any evidence of nausea and vomiting in association with the
2–5
administration of chemotherapeutic drugs ; anorexia or hypersalivation are more commonly seen than overt
vomiting The emetic potential of any chemotherapeutic drug depends on the patient’s sensitivity as well as the route
of administration and drug dose. Some commonly used chemotherapeutic agents and their associated potential to
induce nausea and vomiting are listed below.
Nausea- or Vomiting-Inducing Potential of Selected Chemotherapeutic Agents

Low Moderate High
L-Asparaginase Carboplatin Procarbazine
Bleomycin Cyclophosphamide Dacarbazine
Chlorambucil Cytosine arabinoside Mustargen
Tamoxifen Daunorubicin
Vinblastine Doxorubicin
Steroids Etoposide
Mitoxantrone Methotrexate
Vincristine
197
Any drug given IV can stimulate the central receptors responsible for nausea, vomiting, salivation, or
anorexia within minutes to hours of administration. Similarly, most chemotherapeutic agents can induce these signs 3
to 5 days after treatment because of damage to the gastrointestinal (GI) tract.
The mechanism of chemotherapy-induced nausea and centrally mediated vomiting is complex. The emetic
center in the medulla regulates nausea and vomiting and receives input from at least four sources: the
chemoreceptor trigger zone (CTZ), peripheral receptors, the cerebral cortex, and the vestibular apparatus. The latter
probably does not influence cancer- or chemotherapy-associated nausea and vomiting, and thus drugs such as
diphenhydramine are probably of minimal value in cats. The CTZ is located in the fourth ventricle of the medulla. It is
activated solely by chemical stimuli and plays an important role in chemotherapy-induced nausea and vomiting.
Peripheral receptors can be triggered directly by chemotherapeutic agents or indirectly by substances released by
their effects on other sites; these impulses arrive at the emetic center via the vagus nerve and other autonomic
afferent nerves. Input from higher cognitive centers, a common source of nausea and vomiting in humans, is
sometimes seen in cats. Indeed, cats will occasionally correlate a car ride or the sight of a hospital or treatment room
with a “bad experience” and will salivate profusely and/or develop nausea and vomiting anytime the stimulus is
repeated. Pharmacologic intervention targeted at any or all of these pathways is important for eliminating nausea and
vomiting in cancer patients.
General Concepts of Antiemetic Therapy

As mentioned, most chemotherapeutic agents rarely induce nausea and vomiting in cats shortly after
2–5
administration. Cats that tend to have “tender tummies” after their first dose of chemotherapy are more likely to
experience adverse GI effects following subsequent treatments. They should be treated prophylactically with such
antiemetics as metoclopramide or ondansetron/dolasetron just prior to and up to 10 days after chemotherapy is
administered.
1–3
Self-Limiting Nausea and Vomiting
An underlying cause for acute, potentially self-limiting, nausea and vomiting should be identified and
corrected when possible. Affected animals should be treated as follows:
o Give nothing by mouth until nausea and vomiting have stopped for at least 12 to 24 hours.
o Subsequently, very small amounts of water (e.g., ice cubes) followed by a bland diet can be offered every 2
to 4 hours.
o Once the cat is able to take in food without nausea and vomiting, it can be slowly returned to a normal diet.
During this transition period, a soft, low-fat diet is recommended. Fat is a complex nutrient that is difficult to
digest and therefore may induce diarrhea; compared to some proteins, fat can delay gastric emptying.
o Cats with minimal dehydration can receive fluids subcutaneously; IV therapy is preferred for significantly
dehydrated cats. Many cats improve dramatically shortly after the administration of IV fluids. Potassium
chloride (KCl) supplementation should be provided to prevent and/or treat hypokalemia.
1–3,5
Life-Threatening Nausea and Vomiting
Track A
Cats with severe, life-threatening nausea and vomiting are usually very ill and often obtunded. Treatment is
centered around identifying and correcting the underlying cause. Specific treatment includes administration of
appropriate fluid therapy to severely dehydrated cats (8% to 12% of normal hydration). Deficits in fluid and
electrolytes secondary to dehydration should be replaced during the first 24 hours. Up to 44 ml/kg/day of
maintenance fluids should be administered. Continued losses, such as from vomiting and diarrhea, should be
estimated and replaced. As noted, KCl should be added to fluids to prevent and/or correct hypokalemia, but the
administration rate of KCL should not exceed 0.5 mEq/kg/hour because of the risk for cardiac arrest and death. Cats
should be monitored for fluid overload by monitoring body weight, capillary refill time, skin turgor, packed cell volume,
total solids, and central venous pressure; chest auscultation, is also indicated.
Antiemetics should be employed anytime nausea and vomiting are noted. Once chemotherapeutic agents
cause nausea and vomiting, pretreatment with antiemetics is indicated for all future administrations. For optimum
results, antiemetics should be sent home with owners, who should be instructed to administer the drug
prophylactically or as soon as nausea or vomiting is suspected.
198
Selected Antiemetics for Use in Cats
Product Dose
Chlorpromazine 0.5 mg/kg q6–8h IM, SQ
Prochlorperazine 0.1–0.5 mg/kg q6–8h IM, SQ
Diphenhydramine 2.0–4.0 mg/kg q8h PO
Butorphanol 0.1–0.4 mg/kg q1—4h IM, IV, SQ
Dimenhydrinate 8 mg/kg q8h PO
Maropitant 0.5-2 mg/kg IM, PO
Prochlorperazine 0.5–0.8 mg/kg q12h IM, SQ
Metoclopramide 1–2 mg/kg CRI IV over 24 hours or 0.2–0.5 mg/kg PO q6–8h
Ondansetron 0.1–0.3 mg/kg IV 15 min before and 12 hr after chemotherapy or PO q12h
Dolasetron 0.6–3 mg/kg IV q24h
Dexamethasone 1–3 mg IV
1–3
Metoclopramide
Metoclopramide is one of the most commonly administered antiemetics in veterinary medicine. It is
prescribed to prevent nausea and vomiting and to treat these conditions when they occur at home. Its antiemetic
effect is both central and peripheral. Centrally, it is a dopamine antagonist that blocks the CTZ and prevents emesis;
peripherally, it increases the tone of the caudal esophageal sphincter and increases gastric antral contractions by
relaxing the pylorus and duodenum. This drug should not be administered to cats with GI obstruction.. When
metoclopramide is used with cimetidine, a small percentage of cats will develop extrapyramidal side effects that
resolve shortly after the metoclopramide is discontinued. Metoclopramide can be given to cats at a dose of 0.2 to 0.5
mg/kg PO q6–8h or 1 to 2 mg/kg constant rate infusion over a 24-hour period, preferably through an IV pump.
1–3
Maropitant
Maropitant is a central antiemetic indicated for the treatment of acute feline vomiting, which is often a
postsurgical sequela and a contributor to the pain burden. Maropitant works through a blockade of substance-P
binding to the neurokinin-1 receptor, which is involved in pain processing. The true pain-modifying effect of
maropitant in cats remains uncertain despite canine studies revealing an anesthetic-sparing effect and a non-inferior
effect to morphine in an ovariohysterectomy model.
1–3
Phenothiazines
Phenothiazines (e.g., chlorpromazine, prochlorperazine) are commonly used as antiemetics for mild
chemotherapy-induced nausea; they block the CRT of the emetic center. In human medicine, phenothiazines
generally do not effectively reduce efferent GI irritation. Because these drugs can induce vasodilation, they should
not be used in dehydrated cats or those with poor cardiac output. In addition, phenothiazines can induce mild
Track A
depression and make monitoring patients difficult. All phenothiazines can cause seizures in predisposed animals.
Chlorpromazine can be administered at 0.5 mg/kg IM or SQ q6–8h; prochlorperazine can be dosed at 0.1 to 0.5
®
mg/kg IM or SQ q6–8h. A suppository form (Compazine , SmithKline Beecham) is available for use in select cats that
will allow it to be placed
Narcotic Analgesics
Butorphanol (0.4 mg/kg IM) may help reduce the prevalence of nausea and vomiting in response to
chemotherapy. The drug also has mild analgesic properties. For best results, butorphanol should be administered
intramuscularly shortly after the administration of chemotherapy in cats that tend to become nauseated.
Antihistamines
Antihistamines (e.g., diphenhydramine, dimenhydrinate, trimethobenzamide) block input from the vestibular
system and work against motion-induced nausea and vomiting. Diphenhydramine can be administered at 2 to 4
mg/kg q8h PO; it can cause mild sedation. Although diphenhydramine is rarely of benefit in the treatment of
chemotherapy-induced nausea and vomiting, it can be helpful for cats that get “car sick” on the way to and from the
hospital or clinic.
1–3
Dopamine Antagonists and Diphenylbutylpiperidines
Haloperidol is a dopamine antagonist that blocks the CRT; at a dose of 110 µg/kg, it can prevent nausea and
vomiting for up to 4 days in cats. Pimozide, a long-acting diphenylbutylpiperidine, can protect cats from drug-induced
nausea and vomiting for up to 6 days when given at a dose of 100 µg/kg. Clinical experience with these two drugs is
minimal.
199
1–3
Serotonin Antagonists
Drugs that inhibit the 5-HT-3 (5-hydroxytryptamine) receptor constitute an entirely new and effective class of
antiemetics that is being explored for use in human and veterinary cancer patients. Ondansetron (0.1 mg/kg IV),
several analogs (dolasetron, 0.6 mg/kg IV), and oral preparations are currently available. Serotonin antagonists are
very effective for reducing chemotherapy-induced nausea and vomiting. Although these agents are expensive, they
are affordable for use in cats because of the small size of the patient. Their cost is expected to decline in the future.
1–3
Corticosteroids
Dexamethasone has been shown to have antiemetic activity. Its mechanism of action is unknown. Side
effects are few except in cats with diabetes or gastric ulcers. Relatively small (1 to 3 mg) IV doses are effective in
humans; an appropriate dose for cats is unknown at this time.
The Third Commandment: Don’t Let Them Starve!

Recently, a great deal of information has been published on the nutritional management of the veterinary
1–11
cancer patient. The routine use of nutrient delivery systems, such as nasoesophageal, nasojejunal,
esophagostomy, gastrostomy, and jejunostomy tubes as well as parenteral feeding techniques, has increased
substantially in feline medicine. This has resulted in a better quality of life and better response to therapy for cats that
receive this type of care. Research is needed to delineate the impact that cancer has on the metabolism and quality
and length of life in cats with cancer. In many species, there is a multitude of profound changes in metabolism
associated with the cancer itself. These metabolic derangements occur long before overt weight loss occurs or is
detected and has been termed cancer cachexia. Cancer cachexia is a complex paraneoplastic syndrome of
alterations in metabolism that can eventually result in progressive involuntary weight loss. This occurs even in the
face of adequate nutritional intake. The importance of this syndrome cannot be overstated. For example, humans
with cancer cachexia have a decreased quality of life, decreased response to treatment, and a shortened survival
time compared with patients who have similar diseases but do not exhibit clinical or biochemical signs associated
with this condition. Understanding the metabolic alterations in cats with cancer is essential to providing adequate
nutritional support to these patients. We must be diligent in treating for this syndrome, even though our patients may
not appear clinically “cachectic” and do not exhibit overt symptoms of cachexia until much later in the disease
process. We also must never forget that the most consistent quality of life “markers” that caregivers should monitor
are appetite and nutrition. Educating caregivers about the metabolic ramifications of cancer and then giving them the
tools by which they can affect those ramifications allows the most compassionate care to be delivered. .
Metabolic Alterations in Cancer Cachexia

Cats are obligate carnivores that not only have unique nutritional needs but also unique metabolic processes
that differ from those found in dogs and people. The abnormalities in carbohydrate, protein, and lipid metabolism
associated with cancer in cats are largely unexplored, although at least some are thought to be similar to those found
in other pets and humans. The clinical syndrome of cancer cachexia can lead to serious debilitation and death unless
1–2,12–17
addressed by appropriate therapy. The most important concept is that the metabolic alterations associated
Track A
with cancer cachexia initially are a true metabolic aberration; as such, they occur long before weight loss is observed
and persist for weeks, months, and perhaps years after the malignancies are eliminated. Cancer cachexia is an
insidious, persistent universal syndrome that, left unchecked, will diminish the potential quality and quantity of our
patients’ lives that and must become a priority of our treatment plan for compassionate care to result.
Cats have unique needs for specific amino acids such as taurine. In addition, inadequate amounts of
cysteine can result in Heinz body anemia that can be of serious consequence to the cancer patient. Arginine has
been shown to enhance the immune system in species other than the cat, and glutamine has been documented to
be important to the health and well-being of the entire GI tract. Cancer cells compete with the host for proteins as
energy sources and as building blocks for normal bodily function. Therefore providing a diet that has moderate
amounts of highly bioavailable protein may be logical. Ensuring adequate amounts of taurine, cysteine, arginine, and
glutamine in a palatable form may be helpful. the clinical value of supplementation to levels above nutritional
requirements is unknown.
Abnormalities in lipid metabolism have been linked to a number of clinical problems, including
12–17
immunosuppression, which correlate with decreased survival in affected humans. The clinical impact of the
abnormalities in lipid metabolism may be lessened with dietary therapy. In contrast to carbohydrates and proteins,
some tumor cells have difficulty using lipid as a fuel source, but host tissues continue to oxidize lipids for energy. This
has led to the hypothesis that diets relatively high in fat may be beneficial for cats with cancer compared with diets
that are high in simple carbohydrates, assuming that the protein content, caloric density, and palatability remain
constant. This hypothesis has not been tested in cats. The kind of fat in the diet, rather than the amount, may be the
important factor. For example, omega-3 fatty acids have been shown experimentally to have many beneficial
5,15,16
properties :
200
o Omega-3 fatty acids, arginine, and RNA improve the immune system, metabolic status, and clinical outcome
of human cancer patients.
o When used alone, omega-3 fatty acids improve the immune system and decrease the time for wound
healing, duration of hospitalization, and complication rate in humans with GI cancer.
o Omega-3 fatty acids inhibit tumorigenesis and cancer spread in animal models.
o Essential fatty acids that contain omega-3 fatty acids reduce radiation-induced damage to skin. This seems
to be specific for normal, not malignant, cells.
o Eicosapentaenoic acid not only has antitumor effects but also anticachectic effects, in part because there is
decreased protein degradation without an effect on protein synthesis.
It is essential to determine whether diets supplemented with omega-3 fatty acids improve quality of life and
response to therapy in cats with cancer. At the present time, there is some rational clinical information to suggest that
the addition of omega-3 fatty acids to a diet already fortified with high fat levels, moderate protein levels, and lower
carbohydrate levels may be helpful in supporting feline cancer patients. It is imperative that, regardless of the diet,
patients consume adequate nutrients to prevent weight loss.
Nutrient and Water Needs

Our knowledge of the nutrient and water needs of cats is primarily based on work done many years ago or
extrapolated from research completed on rodents or humans. The majority of data concerning energy and water
18
requirements in cats may be overestimated. For example, it has been determined that the resting energy
expenditure, which is an estimate of the nutrient and water needs of normal cats, is lower than indicated by
18
previously published data. What this means to the practicing veterinarian is that most of the recommendations for
the amount to be fed are overestimated for the majority of cats. Caloric requirements differ for each cat, and
therefore each cat should be periodically reassessed and individualized in health and disease.
Less Proven Nutrient Claims

Many clients come to our doors requesting guidance on the use of nutrients for their cats with cancer and
other diseases. Many caregivers are utilizing the internet and numerous alternative sources for information to help
their cats. It is vital that we are able to explain what is known and not known and guide caregivers in their selection of
supplements to assure that no harm is done to the patient. The nutritional requirements of cats are unique, and
extrapolating from rats, dogs, or humans can be dangerous. The following section is designed to provide some
awareness of some vitamins and other nutrients that have been mentioned in the literature or lay press. Very little
information is known about the efficacy of these nutrients in the cat.
Vitamins
Retinoids, beta carotene, and vitamins C, D, and E may influence the growth and metastasis of cancer cells
19–28
via a variety of mechanisms. These vitamins fall into and out of popularity based on the results of select studies
and the lay press. The weight of the literature would suggest, however, that many of these vitamins may be of value
Track A
for some cancer patients. Select examples of the impact of a few vitamins are included below.
Retinoids
Retinoids are not used as a mainstay of cancer therapy; however, there is a growing body of knowledge
about the anticancer effect of this vitamin in humans and animals. In humans, 13-cis retinoic acid prevents secondary
19–22
tumors in patients treated for squamous cell carcinoma of the head and neck and can reverse the effects of
cervical human papillomavirus infection. Retinoic acid, when used in the adjuvant treatment of retino-blastoma (a
childhood cancer), lead to translocation of bound receptor vitamin complexes to the nucleus, which results in the
20 20
regulation of the neuroblastoma gene. Melanoma in mice has been successfully treated with retinoids.
The efficacy of retinoids is not confined to rodents and people. A study was recently completed to evaluate
the synthetic retinoid isotretinoin and etretinate to treat dogs with intracutaneous cornifying epithelioma (ICE), other
21
benign skin neoplasias, and cutaneous lymphoma. This study showed reduction in the size of some tumors and
elimination of others. Little is known about the antitumor effect of retinoids in cats, although there is
possible/anecdotal evidence suggesting some efficacy for the treatment of actinic keratosis (precancer) on the face
of light pigmented cats
Vitamin C
Vitamin C has been studied continuously over the last several decades as an antioxidant and an agent that
can effectively treat conditions such as colds, cardiovascular disease, and cancer. There have been some data
15–17
suggesting that vitamin C may be of value for the prevention and treatment of certain types of cancers. Water-
soluble vitamin C has been widely reported to inhibit nitrosation reactions and prevent chemical induction of cancers
16–17
of the esophagus and stomach. Processed foods high in nitrates and nitrites, such as bacon and sausage, are
often supplemented with vitamin C to reduce the carcinogenic capability of the resultant nitrosamines.
201
A human tissue culture line resistant to vincristine that was established from a small cell lung cancer cell line
was pretreated with ascorbic acid, resulting in potentiation of the vincristine effects on resistant but not sensitive cell
15,16
lines. Therefore, ascorbic acid may be one therapeutic alternative for overcoming a drug resistance in some
cancer cells.
Vitamin E
Lipid-soluble vitamin E, or alpha tocopherol, can also inhibit nitrosation reactions, but in addition, vitamin E
22–24
has a broad capacity to inhibit mammary tumor and colon carcinogenesis in rodents. In addition to its
23–25
chemopreventative properties, vitamin E may convey potential therapeutic efficacy against certain malignancies.
This vitamin does so due to its antiproliferative activity. Additional studies have been initiated in humans at Harvard
School of Public Health. Additional studies are essential to allow further clarification of the value of these vitamins.
Minerals
Minerals that have been suggested as having chemopreventative or anticancer effects and that are of value
as nutrients include selenium, copper, zinc, magnesium, calcium, lead, iron, potassium, sodium, arsenic, iodine, and
germanium. Selenium has been one of the most heavily studied minerals associated with the development of
25–28 25
cancer. Low serum selenium levels have been seen in human patients with prostate and GI cancer. In rodents,
dietary supplementation of selenium has been shown to inhibit colon, mammary gland, and stomach
26–28
carcinogenesis. Additional study is essential to determine whether alteration of selenium levels would be of value
for the treatment of veterinary or human cancer patients. Selenium may be toxic at high levels and thus should not be
supplemented without first seeking advice from a veterinary nutritionist.
15
Iron transferrin and ferritin have been linked to cancer risk and cancer cell growth. Lung, colon, bladder,
and esophageal cancer in humans have been highly correlated with increased serum iron and increased transferrin
15–16
saturation. This may be because many tumor cells require iron for growth.
Therapeutic Enzymes
Enzymes have therapeutic potential but limited approval in the United States. L-Asparaginase is probably the
29
most valuable therapeutic modality for the treatment of lymphoma and leukemia in animals and humans. Oral
enzyme preparations are used for the treatment of chronic pancreatic insufficiency and disaccharidase deficiency.
Several enzyme preparations are available in Europe for oral adjuvant treatment of cancer and other diseases. Of
those, Wobenzyme™ and Musal™ contain a similar mixture of enzymes. Recent studies report efficacy of
therapeutic enzymes in the treatment of cancer patients, the mechanism of which is not precisely known. One
hypothesis is that these enzymes eliminate pathogenic immune complexes. Therefore enzymes may indeed be of
value for the adjuvant treatment of cancer.
Protease Inhibitors
A great deal of information suggests that soybean-derived Bowman-Birk inhibitor (BBI) can inhibit or
Track A
30–34
suppress carcinogenesis both in vivo and in vitro. Extracts of BBI have been shown to inhibit carcinogenesis in
several animal model systems, including colon- and liver-induced carcinogenesis in mice, anthracene-induced cheek
30–34
pouch carcinogenesis in hamsters, lung tumorigenesis in mice, and esophageal carcinogenesis in rats. BBI
concentration has been shown to inhibit metastasis and weight loss associated with radiation-induced thymic
33
lymphoma in mice. Irradiated rodents treated with dietary BBI concentration have fewer deaths, lower average
grade of lymphoma, and larger fat stores than controls. Therefore this protease inhibitor from soybeans may be
important as an adjunct to cancer chemotherapy protocols and in the prevention of secondary cancers.
Nutritional Support for Cats with Cancer

Theoretically, the ideal way of treating cancer cachexia should be to eliminate the underlying neoplastic
condition. Unfortunately, this is not possible for many cats. In addition, in published studies in other species, the
metabolic ramifications of cancer cachexia persist even after the patient is rendered free of disease. Therefore
dietary therapy has been examined as a modality to reverse or eliminate cancer cachexia. Investigators have raised
concerns about the possibility of increasing tumor growth by enhancing the nutritional status of the host. Several
studies have failed to show this correlation. The benefits that have been shown with dietary support include weight
gain and increased response to and tolerance of radiation, surgery, and chemotherapy. Other factors that have been
shown to improve with nutritional support include thymic weight, immune responsiveness, and immunoglobulin and
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complement levels as well as the phagocytic ability of white blood cells.
The single biggest concern in the nutritional support of the feline cancer patient is the prevention and
treatment of anorexia. Several steps can be taken, including:
o Provide a variety of fresh aromatic foods that are warmed to just below body temperature. Cats are
intermittent eaters, hence they should be provided some food constantly.
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o Prevent and treat pain with appropriate analgesia. Cats are stoic and will not commonly exhibit pain in any
way other than by exhibiting anorexia.
o Prevent and treat nausea. Cats do not commonly vomit when they are nauseated, but like other species,
they become anorectic.
o Prevent and treat dehydration. Subclinical dehydration results in anorexia in most species. When in doubt,
provide SC or IV fluids.
o When the above has not worked, consider the addition of appetite stimulants such as cyproheptadine (total
oral dose, 2 mg q12–24h) and megesterol acetate (0.25–0.5 mg/kg daily for 3–5 days then q48–72h
thereafter). In some cases, a combination can be quite effective. In the hospital, diazepam (0.05–0.1 mg/kg
IV administered in a single dose as needed may be used to enhance appetite.
o When oral intake is not possible, assisted tube feeding with esophagostomy, gastrostomy, nasoesophageal,
or weighted nasojejunal tube should be considered.
Rodents and humans with cancer that consume diets containing 30% to 50% of nonprotein calories as fat
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have increased nitrogen and energy balance as well as increased weight gain. This type of diet also results in
slower tumor growth and decreases in both glucose intolerance and fat loss. Although the ideal dietary formulation
for cats is unknown, these facts may serve as guides for future research in this area. This is a starting point for cats
with cancer. The remainder of this section contains general guidelines for dietary therapy of feline patients with
cancer.
Parenteral Nutrition
Parenteral nutrition should be considered for cats with cancer whenever enteral feeding is not feasible.
Parenteral feeding does require some specialized equipment (e.g., pumps) and strict aseptic technique, but the
procedure can safely be carried out in private practice.
Administration and Complications

In feline medicine, parenteral nutrients are preferably administered through a dedicated single-lumen
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polyurethane catheter or a more expensive multilumen catheter. It is essential to ensure that the catheter remains
sterile to reduce the incidence of catheter-induced sepsis. Most veterinary centers that administer parenteral
nutrients use IV pumps to ensure a constant rate of infusion. The rate of infusion is simplified if lipid is used to
provide a percentage of nonprotein calories, because dextrose-containing fluids need to be gradually increased over
several days.
With proper technique and patient care, problems associated with the administration of parenteral nutrition
are relatively uncommon. Complications can result from destruction or occlusion of the catheter or tubing and pump
failure; however, the most serious complication is related to catheter- or solution-related sepsis, which can be
avoided by using aseptic technique. Other complications include metabolic and electrolyte abnormalities, including
lactic acidosis. Mildly elevated serum urea nitrogen levels and hyperglycemia with glucosuria occasionally occur in
cats receiving parenteral nutrient therapy. Hypokalemia is perhaps the most common electrolyte disturbance related
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to the administration of parenteral nutrition, but it is easily corrected with additional potassium supplementation.
Calculating Contents and Volumes

Although recent research may suggest that cats with cancer do not have increased requirements, the
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determination of the amount of parenteral solution for the cat is relatively straightforward.
Energy Requirements
0.75
o The basal energy requirement (BER, in Kcal/day) is calculated by multiplying 70 by the cat’s weight in kg .
More simplistically, the weight of the cat in kg is multiplied by 30 and then added to 70.
o To get the maintenance energy requirement (MER, in kcal/day) for normal cats that are at rest in a cage, the
BER is multiplied by 1 to 1.25. For cats that have undergone recent surgery or that are recovering from
trauma or cancer, the BER is multiplied by a factor of 1.25 to 1.5 to determine the illness energy requirement
(IER). For cats that are septic or have major burns, the BER is multiplied by 1.7 to 2.0. This may be an
overestimate for many patients.
o To calculate the volume of the formula required, divide the MER by the kcal/ml of that formula to get the
milliliters of formula per day.
Lipid and Carbohydrate Requirements

o Most authors recommend giving 40% to 60% of the nonprotein calories as lipid and the balance of
nonprotein calories as dextrose. Therefore, because a 20% lipid solution has 2 kcal/ml, 40% to 60% of the
IER is divided by 2 kcal/ml to yield the volume of the lipid solution to administer. The rare lipemic cat should
not be given lipid-containing solutions.
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o To determine the volume of a 50% dextrose solution to be administered (1.7 kcal/ml), divide 40% to 60% of
IER by 1.7 kcal/ml. Because the volume of the dextrose-containing fluids should be increased gradually, half
of this calculated volume should be administered on the first day and gradually increased to the full amount
over the next day or two.
Enteral Nutrition
The standard dogma is that enteral nutrition should be considered for mature cats with functional GI tracts
and a history of inadequate nutritional intake for 5 to 7 days or that have lost at least 10% of their body weight over a
1 to 2 week period. Current thinking is that enteral feeding techniques should be employed for all cats long before
approaching 10% body weight loss. Indeed, clients should be counseled about the importance of nutritional therapy,
including assisted feeding techniques, from the onset. In situations where therapy is likely to be prolonged, the
“prophylactic” use of enteral feeding should be considered. In order to optimize appetite, nausea and discomfort
should be treated appropriately. In addition, even subclinical dehydration should be treated aggressively. For
example, a feline patient will experience loss of appetite at approximately 2% to 3% dehydration, a level far below
clinical detection. Thus judicious use of SC or IV fluid administration may actually be a diagnostic and therapeutic
tool in the inappetent patient.
All methods to encourage food consumption should be attempted.These include warming the food to just
below body temperature, providing a selection of palatable, aromatic foods, and providing comfortable, stress-free
surroundings. When these simple procedures fail, such chemical stimulants as benzodiazepine derivatives (e.g.,
diazepam and oxazepam) and antiserotonin agents (cyproheptadine and pizotifen) can be used. Cyproheptadine (2–
4 mg PO daily or twice daily) generally is effective in stimulating appetite in cats, as are megestrol acetate (0.25-0.5
mg/kg daily for 4 days, then every 2–3 days thereafter) and diazepam (0.05–0.5 mg/kg IV). Cats may have improved
appetite when metoclopramide is given orally to decrease nausea associated with chemotherapy or surgery. When
all the aforementioned fails, enteral nutritional support, designed to deliver nutrients to the GI tract by various
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methods, should be considered because it is practical, cost-effective, physiologic, and safe.
Routes of Enteral Feeding

Nasoesophageal Tubes
This is still the most common feeding method used today, although esophagostomy and weighted
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nasojejunal tubes are becoming more popular. The use of small-bore, silastic or polyurethane catheters has
minimized complications associated with this delivery system. The procedure is simple to perform.
1. Tranquilization is sometimes required during placement of the tube, especially in cats. The swallowing reflex
is important to be able to pass the tube into the esophagus and not into the trachea. To decrease any
discomfort associated with the initial placement of the catheter, lidocaine is instilled into the nasal cavity with
the nose pointed up. Care should be taken not to get any lidocaine into the mouth as it has a bad taste. It
may be helpful to place a finger on the septum and push the cat’s nose back parallel to the long axis of the
head, thereby straightening the nasal passageway.
2. The tube is lubricated and passed to the level of the cat’s ninth rib.
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3. After the tube has been properly placed, it should be secured. In cats, the tube should be bent dorsally over
®
the bridge of the nose and secured to the frontal region of the head with a permanent adhesive (Superglue ,
Loctite Corp, Cleveland, OH). A suture may be used to further secure the tube in place. Care should be
taken to prevent any contact with the whiskers.
4. An Elizabethan collar should always be used to prevent the patient from removing the tube.
Weighted Nasojejunal Tubes

Weighted nasojejunal tubes are often preferred over nasogastric tubes because they can bypass the
stomach to deliver liquid nutrients into the intestine, which is especially valuable in cats that are vomiting. The use of
small-bore, silastic or polyurethane catheters with a flexible weighted tip has minimized complications associated
with this delivery system. This system should be considered when short-term enteral nutritional intervention is
needed. The procedure is simple to perform.
1. Placement of the tube begins as step 1 for nasoesophageal tubes. In cats with ileus or poor gastric motility,
anesthesia should be employed and an endoscope should be used to bring the weighted tube into the
duodenum. Alternatively, if a gastrostomy tube has already been placed, a weighted nasojejunal tube can be
advanced into the stomach through the tube, which can be ideal, especially for cats that vomit.
2. The tube is lubricated and passed beyond the level of the ninth rib in cats. Normal esophageal, gastric, and
intestinal peristalsis will often sweep the weighted end into the intestine. Alternatively, an endoscope can be
used to place the tube into the intestine.
3. The tube is secured as for nasoesophageal tubes.
4. An Elizabethan collar should always be used to prevent the patient from removing the tube.
5. Oddly enough, despite the fact that the tube is essentially a linear foreign body, removal is done by gentle
traction. The tubes slip through the intestines and stomach quite easily.
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Esophagostomy vs Gastrostomy Tube
Recently, esophagostomy tube feeding has gained great popularity because they tubes can be placed easily
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without special equipment, removed at any time, and require no waiting time before feeding begins . Fourteen to
twenty French (Fr) tubes are used in cats. Esophagostomy tubes can be placed percutaneously with the use of a
curved carmault or hemostat. Complications ut include local cellulitis and occasionally a dissecting abscess of the
cervical tissues; these complications are rare and heal up shortly after the tube is removed and the local reaction
treated appropriately.
Many practitioners prefer to place esophagostomy tubes rather than gastrostomy tubes in all cats that have a
functional upper GI tract except those that have esophageal motility disorders, such as megaesophagus. The
esophagostomy tubes are easier to place, maintain, and remove than gastrostomy tubes. Many caregivers appear to
accept esophagostomy tubes over gastrostomy tubes.
Esophagostomy Tube Placement

1. The cat is placed under anesthesia and the left lateral cervical skin is clipped and prepared for surgery. The
esophagostomy tube (e.g., red rubber feeding tube or JorVet J-390 14 Fr, 9" tube is placed in the midcervical
region between the lateral spinous processes dorsally and the jugular vein and carotid artery ventrally.
2. A curved hemostat is placed down the mouth and into the esophagus, halfway between the angle of the jaw
and the thoracic inlet. The curved portion of the instrument should point laterally..
3. The hemostat is then further directed laterally so that it “tents” the esophagus and overlying skin by pushing
the tip against the left lateral esophageal wall. A small incision (0.25–0.5 cm) is made over the tip of the
hemostat. The key is to make a tiny incision through the esophagus just big enough to see the tip of the
instrument. The instrument is pushed through the surgically created hole in the tissue. The jaws of the
carmault or hemostat are opened and the tip of the red rubber feeding tube is grasped with the instrument
and pulled partially through the skin and out the mouth. The tube is then pushed aborally down the
esophagus with the hemostat to the level of the ninth rib in cats. The objective is to not allow the tip of the
tube to go into the stomach to prevent any vomiting or reflux esophagitis.
4. The esophagostomy tube is then sutured into place and a light wrap is placed over the tube. Note that
blenderized commercial diet can begin as soon as the patient can tolerate enteral feeding, usually within 24
hours. The amount of kcals provided is generally 25% to 50% of daily need; it is divided, administered every
4-8 hours, and then increased daily as fast as the cat can tolerate full feeding. Metoclopramide is often
added to enhance normal GI motility.
Gastrostomy Tube
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These are used frequently for cats that need nutritional support for more than 7 days. These tubes can be
placed surgically or with endoscopic guidance. A 5 ml, 18 to 24 Fr balloon-tipped urethral catheter (e.g., Foley
catheter, Bardex, Murray Hill, NJ) can be placed surgically, as can a mushroom-tipped Pezzer proportionate head
urologic catheter (Bard Urological Catheter, Bard Urological Division, Covington, GA). Complications associated with
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gastrostomy tubes may include local or diffuse peritonitis, bleeding, cramping, vomiting, and diarrhea.
Gastrostomy Tube Placement

1. General anesthesia is required for the placement of a gastrostomy tube. Prior to placement of the tube, the
left pericostal area just below the paravertebral epaxial musculature is clipped and prepared for surgery. A 2
to 3 cm incision is made just caudal to the last rib through the skin and subcutaneous tissue to allow blunt
dissection through the musculature into the abdominal cavity.
2. The stomach is inflated through a tube that is placed down the esophagus to allow the surgeon to easily
locate the stomach through the opening in the abdominal wall. Stay sutures are placed to allow a temporary
fixation of the stomach against the abdominal wall; these stay sutures are used later to help close the
muscular wall.
3. Two concentric pursestring sutures of 2-0 nonabsorbable nylon suture are then placed deep in the stomach
wall; the first pursestring is deep to the second purse string to allow a two-layered closure.
4. The feeding tube is placed into the lumen of the stomach through a stab incision in the middle of the
pursestring sutures. The tip of the catheter generally is clipped off to allow easy introduction of food through
the tube and into the stomach.
5. Once the tube is in place, the balloon is inflated with water if the balloon-tipped catheter is used; the Pezzer-
tipped catheter has an expanded head that flattens and then returns to its normal shape when a stylet is
extended and then removed in the catheter lumen during placement through the stab incision into the
stomach.
6. With the tube in place, the pursestring sutures are tied to cause the stomach to invert in the region adjacent
to the tube. The free ends of the sutures are then used to close the lateral abdominal musculature and
subcutaneous tissue.
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7. The skin is closed before the tube is secured to the abdominal skin by sutures. To prevent the cat from
removing the tube, an abdominal wrap and an Elizabethan collar are recommended.
Feeding can begin 24 hours after the cat has recovered from anesthesia. The tube should be checked daily
to ensure proper placement. In addition, the tube should be flushed with warm water after each feeding to maintain
patency. After 7 to 10 days, an adhesion will form, allowing the tube to be removed or replaced as needed. The
fistula generally heals within a week after the tube is removed permanently. Closure of the fistula is not needed.
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Percutaneous placement of a gastrostomy tube by endoscopic guidance is quick, safe, and effective.
In this procedure a specialized 20 Fr tube (e.g., Dubhoff PEG, Biosearch, Somerville, NJ; Bard Urological Catheter,
Bard Urological Division, Covington, GA) is used in all but the smallest cats. Low profile gastrostomy tubes are
available.
1. General anesthesia is also required for percutaneous placement of gastrostomy tubes. Clip and surgically
prepare the area of skin outlined previously (left lateral abdomen), and then distend the stomach with air
from an endoscope that is placed into the stomach.
2. Once the stomach is distended to the point that it is in apposition with the body wall, a finger is used to
depress an area just caudal to the last left rib below the transverse processes of the lumbar vertebrae. This
area of depression is then located by the person viewing the stomach lining by endoscopy.
3. A polyvinyl chloride (PVC) over-the-needle IV catheter is placed through the skin and into the stomach in the
area previously located by the endoscopist. The stylet is removed to allow the introduction of the first portion
of a 5 foot long piece of 8 lb test weight nylon filament or suture.
4. The piece of nylon is grabbed by a biopsy snare passed through the endoscope. The endoscope and the
attached nylon are pulled up the esophagus and out the oral cavity so that the piece of nylon extends
through the body wall and out of the mouth of the cat.
5. The end of the gastrostomy tube opposite the mushroom tip is trimmed so that it has a pointed end that will
fit inside another PVC catheter, after the stylet is removed and discarded. This second PVC IV catheter is
then placed over the nylon suture so that the narrow end points toward the stomach. The free end of the
nylon that has just been pulled out of the cat’s mouth is sutured to the end of the tube and tied securely.
6. The catheter–tube combination is pulled firmly but slowly from the end of the suture located outside the
abdominal wall until the pointed end of the IV catheter comes down the esophagus and out the abdominal
wall.
7. The tube is grasped and pulled until the mushroom tip is adjacent to the stomach wall, as viewed by
endoscopy.
8. To prevent slippage, the middle of a 3 to 4 inch piece of tubing is pierced completely through both sides and
passed over the feeding tube so that it is adjacent to the body wall. This bumper or retainer is then glued or
sutured securely in place. The tube is capped and bandaged in place.
An Elizabethan collar is almost always required to prevent the cat from removing the tube. To remove the
tube once it has been in place for 7 to 10 days, the tube just below the bumper is severed to allow the “mushroom”
tip to fall into the stomach. This piece should be removed by an endoscope. Some commercially available “low
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profile” gastrostomy tubes are designed to be removed with a stylet that is used to straighten out the tube and
balloon for removal.
Needle Catheter Jejunostomy Tubes

These tubes should be considered for cats will not tolerate nasogastric or gastrostomy tube feeding but that
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have a functional lower intestinal tract. This method is especially valuable in cancer patients that have had surgery
to the upper GI tract. Complications with this method are similar to those seen with gastrostomy tubes. The
procedure is as follows:
1. The distal duodenum or proximal jejunum is located and isolated by surgery. A pursestring suture of 3-0
nonabsorbable suture is placed in the antimesenteric border of the isolated piece of bowel.
2. A 12-ga needle is placed from the serosa located at the center of the area encircled by the pursestring
suture, subserosally 2 to 3 cm through the wall of the intestine, into the lumen of the loop of bowel.
Alternatively, a stab incision can be made into the same location of the bowel using a No. 11 surgical blade.
3. A 5 Fr nasogastric infant feeding tube is passed through the hypodermic needle or the stab incision to an
area down the bowel, 20 to 30 cm from the enterostomy site.
4. If a needle was used, it is then removed.
5. The pursestring is tightened and secured around the tube.
6. The free end of the feeding tube is passed from the serosal surface of the abdominal wall out of the skin
through a second hypodermic needle.
7. The loop of bowel with the enterostomy site is secured to the abdominal wall with four sutures that are later
cut after the tube is removed in 7 to 10 days, when feeding is complete.
8. An abdominal wrap and Elizabethan collar are recommended to prevent the cat from removing the tube.
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Enteral Feeding Methods
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The type of nutrients to be used depends largely on the enteral tube used and the status of the patient.
Blended canned pet foods may be adequate for feeding by gastrostomy tubes, and human enteral feeding products
are easily administered though nasogastric and jejunostomy tubes. In any case, feeding usually is not started until 24
hours after the tube is placed. Once feeding is started, the amount of nutrients is gradually increased over several
days and is administered frequently in small amounts, which allows the cat to adapt to this method of feeding.
Continuous feeding may reduce the risk of vomiting caused by overloading the GI tract. Regardless, the tube should
be aspirated three to four times a day to ensure there is not excessive residual volume in the GI tract. A column of
water should be kept in the tube at all times and the tube should be flushed periodically with warm water to prevent
clogging.
Calculating Contents and Volumes

Calculation of the nutritional requirements for enteral feeding is essentially the same as for parenteral
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feeding noted earlier. The energy requirement for the cat with cancer is calculated. It should be kept in mind that
some patients have a very high energy expenditure that may exceed those seen in cats that have infections, sepsis,
or burns. Other research suggests that the energy needs of most cancer patients do not exceed that of healthy cats.
It is essential that once an IER is determined that the patient be monitored for weight gain/loss and adjustments
made to maintain optimum weight. Cats with renal or hepatic insufficiency should not be given high protein loads (>4
g/100 kcal). Because most high quality pet foods can be put through a blender to form a gruel that can be passed
through a large feeding tube, the IER of the cat is divided by the caloric density of the canned pet food to determine
the amount of food to feed. The same calculation can be done with human enteral feeding products; the volume fed
may need to be increased if the enteral feeding product is diluted to ensure it is approximately iso-osmolar before
administration.
Specifics of Diets for the Cancer Patient

Product Caloric Content Protein Content Fat Content Osmolarity
(kcals/ml) G/100 kcal-g/ml (g/100 kcal) (mOsm/kg)
Feline a/d 1.30 8.06-0.105 5.07
a
Feline p/d 0.8 10.89-0.087 7.13
b
Feline k/d 0.64 5.62-0.036 7.88
b
Feline c/d 0.62 9.02-0.56 6.04
Canine nd 0.62 7.2-0.056 5.9
Jevity 1.06 4.20-0.045 3.48 310
Osmolite HN 1.06 4.44-0.047 3.68 310
Vital HN 1.0 4.17-0.042 1.08 460
Vivonex HN 1.0 4.60-0.046 0.90 810
Clinicare Feline 1.0 8.60-0.086 5.30 235
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a
Blenderize 0.5 can (225 g) + 0.75 cup (170 ml) water
b
Blenderize 0.5 can (224 g) + 1.25 cups (284 ml) water
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42. Kennedy AR: Effects of protease inhibitors and vitamin E in the prevention of cancer, in Prasad KN and
Meyskens FL (eds): Nutrients and Cancer Prevention. The Humana Press, Inc, 1990, pp 79–98.
43. Witschi H, Kennedy AR: Modulation of lung tumor development in mice with the soybean-derived Bowman-Birk
protease inhibitor. Carcinogenesis 10:2275–2277, 1989.
NOTES:
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NOTES:
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210
Care Beyond a Cure: Diagnostic Secrets and the Cancer Patient

Introduction
The three golden rules in feline oncology are: biopsy, biopsy, biopsy! In order to determine prognosis,
treatment options and palliative care, one must know the histopathological name and in many instances the grade of
1-4
the cancer. These golden rules are the keys to the successful management of almost any cat with cancer and
need be coupled with answers to the above questions concerning timing of the biopsy procedure. . This is critical in
feline oncology because, unlike other species, “salvage” procedures have a much lower chance for success in the
cat and therefore, the definitive treatment must be handled correctly the first go around. In addition, the cat is smaller,
and due to the advanced stage of many malignancies, its physical condition is likely to be more fragile and thus the
definitive procedures must be planned with care.
A minor limitation in the feline oncology biopsy procedure is the size of the cat versus the large size of the
instruments designed for biopsies in human medicine. This challenge rarely precludes obtaining tissues for biopsy,
but does require some creative planning of the procedure, which is necessary to form a definitive treatment.
Summary Guidelines for Obtaining a Successful Biopsy Sample

o Biopsy should only be performed after consultation with the surgeon who will perform the definitive surgery to
formulate a correct plan for the biopsy such that follow-up surgical procedures will not be made more difficult
or less potentially successful.
o Obtain as large of a sample as possible.
o DO NOT over use electrocautery or laser energy or any surgical instruments that can potentially crush or
otherwise damage tissues.
o Ensure that the tissue is adequately fixed in a 10% buffered, neutral formalin solution.
o Place each biopsy sample in a separate container and properly label the container of each sample.
o Submit the entire lesion, whenever possible, after it has been resected and properly prepared for fixation.
o Consider submitting portions of the lesion for culture and sensitivity or other analysis.
o Submit the biopsy to a highly qualified veterinary pathologist. Remember that an anatomic pathologist can
best evaluate biopsies and a clinical pathologist best analyzes cytology.
The biopsy is one of the most important procedures performed when evaluating a cat with cancer. Biopsy
results must be interpreted carefully in conjunction with results of other diagnostic procedures such as bloodwork,
radiographs, and other imaging modalities. A biopsy specimen is only of value if it is taken and prepared properly,
and then interpreted by a highly trained pathologist who is willing to use all of the clinical information available to
Track A
arrive at an accurate diagnosis.
Each biopsy should be performed with the assumption that the lesion is malignant. Therefore, the biopsy
should be done so that the entire surgical field, including all tissues or tissue planes that may have been disturbed,
and any post biopsy hemorage/hematoma can be removed by a subsequent surgery. Second surgeries performed
to remove the tumor and surrounding tissues frequently involve going at least one fascial layer below the tumor and
all tissues disturbed by the previous surgery.
Several types of biopsies exist. These include needle core biopsies, incisional biopsies (otherwise known as
"wedge" biopsies), and excisional biopsies. A small core of tissue is obtained with a needle core biopsy versus a
portion of the tumor being removed for an incisional or “wedge” biopsy. Incisional biopsies are generally taken at the
junction of normal and abnormal tissue, and are preferred in cases where a punch or needle biopsy cannot provide
an adequate tissue sample for analysis. Regardless of the type, the biopsy procedure must be performed correctly so
that it will not compromise subsequent curative resection. The entire tumor is removed with an excisional biopsy,
which is the preferred procedure in cases where the knowledge of the tissue type will not influence the definitive
procedure or treatment plan (e.g., a solitary lung mass or a splenic mass).
As mentioned above, the biopsy should be performed prior to definitive therapy if:
1. results will alter the type of therapy to be employed or
1
2. results will influence the owners’ willingness to treat their cat.
For example, with a biopsy result of a benign basal cell tumor, a clinician can confidently proceed to perform
a small resection. However, if the biopsy result reveals that the mass is a high grade, vaccine-associated sarcoma,
which is a more aggressive tumor, then wide surgical resection with 2- to 3-cm margins around the periphery of the
tumor is required, and adjunctive therapy may be recommended. For financial or emotional reasons, some owners
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may be more willing to treat a cat with a benign basal cell tumor than one with a more malignant vaccine-associated
sarcoma.
1,2
Guidelines
1. Biopsies DO NOT negatively influence the survival of the patient when taken appropriately. The myth that the
biopsy procedure causes cancer cells to spread throughout the cat’s body, resulting in an early demise of the
patient, is not supported in the scientific literature.
2. A biopsy should be performed after consultation with the surgeon who will perform the definitive surgery.
This gives the surgeon the information necessary to ensure that the lesion and the entire biopsy tract are
removed to allow for adequate resection of the mass and biopsy site without “spilling” or “seeding” tumor
cells into the surgical field. In addition, the biopsy incision should be oriented to cause the least amount of
tension on the skin, which will make a subsequent definitive surgical procedure less complicated. In general,
but with some exceptions, the direction of the incision should be made like the stripes on a tiger to minimize
skin tension and maximize the amount of tissue that can be removed around the tumor.
3. Obtain as large of a sample as possible in order to assist the pathologist in making a correct diagnosis. With
an incisional biopsy, the juncture of normal and abnormal tissue is an ideal site for sampling of the tumor.
Osteosarcoma, or any tumor involving bone, is an exception to this rule. In these suspected cases, biopsy
specimens should be taken from the center of the tumors because the periphery of the lesion is composed
primarily of reactive bone. Ulcerated, necrotic tissue should not be biopsied unless absolutely necessary,
because the secondary pathologic lesions may obscure the primary diagnosis. In addition, if needle core
biopsies are obtained, multiple samples should be taken throughout the tumor (minimum of 3-5).
4. Original architecture of the tissue sample should be maintained; therefore, electrocautery, laser or surgical
instruments that crush or otherwise damage tissues should not be used.
5. Ensure that the tissue is adequately fixed in 10% buffered, neutral formalin (1 part tissue to 10 parts fixative).
Fresh tissue should be placed in fixative for 24 to 48 hours. Most pathologists prefer 10% buffered formalin;
however, fixatives such as Zenker’s or Bouin’s can be used for special purposes, such as tissues from the
eye. For best results, tissue should not be thicker than 1 cm to ensure proper exposure to the fixative. If an
excisional biopsy is performed and the entire tissue is larger than 1 cm, the sample can be cut like a loaf of
bread to allow proper exposure of the tissue to the fixative.The exception to this rule is brain tissue, which
can be fixed intact without the bread-loafing technique. Very thin samples should be avoided because the
fixation process can distort the tissue architecture. The tissue should not be exposed to heat, cold, or water
at any time.
6. Each biopsy specimen should be placed into a separate, properly labeled container. The container should be
labeled on its side instead of the lid to prevent mix-ups if the tops are switched. If multiple biopsies are
performed, all containers should be labeled prior to the procedure to reduce the chance of confusing
samples.
7. When possible, all resected tissue should be prepared properly and submitted for proper analysis. This will
enable the pathologist to examine the tissue for completeness of removal (“clean” or “dirty” margins) and
Track A
architectural detail. Trimming the biopsy specimen or submitting only a small section means that this
valuable information may be lost. However, if mailing costs must be reduced, then smaller, representative,
adequately fixed tissue samples can be sent in just enough formalin to keep them moist. Tissues that are
adequately fixed in formalin can be placed in sealable sandwich bags with a formalin-saturated paper towel
or sponge. The original tissue should be kept in the event that additional samples are needed. Overfixation
may decrease the chances of successful immunohistochemistry. All margins should be marked with ink or
suture and submitted to determine adequacy of surgical excision. If necessary, again to decrease size of
sample submission, these margins may be submitted separately from the primary tumor.
8. After a tissue is biopsied, consideration should be given to submitting portions for culture and sensitivity or
alternate analysis (e.g., electron microscopy). For best results, it is essential to plan which types of samples
are to be submitted and analyzed before preparing the biopsy sample. Once the tissue is in the formalin,
other tests or analyses may not be possible.
9. Biopsy specimens should be submitted to a highly qualified veterinary pathologist who is willing to work with
the clinician. In addition:
o The pathologist should be given a detailed history and a complete account of all relevant clinical
material.
o Margins should be identified with ink or suture. The pathologist will then have all the information
necessary to make an accurate diagnosis.
o It is important for the clinician and pathologist to work together to help the clinical picture fit with the
pathologist’s diagnosis. If these do not match, then together, the clinician and pathologist should
reevaluate the case with all of the information, including the histopathology. This cooperative
interaction is essential for the cat’s benefit and allows for a more successful plan of action.
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o Board-certified, anatomic pathologists are the people best qualified to analyze histopathologic
specimens whereas board-certified clinical pathologists are most appropriate to evaluate cytology,
hematology and biochemical problems.
Contraindications
In each case, the risks and benefits of the biopsy should be evaluated and clearly described to the owner. In
most cases, the risks are minimal. Uncontrollable hemorrhage is the most common complication with all biopsy
procedures except, perhaps, bone marrow aspiration and biopsy. Therefore, before each biopsy, hemostatic
abnormalities should be identified and corrected. Aseptic technique in biopsy procedures is critical to avoid the
uncommon but serious complications of infection at the local biopsy site and/or sepsis in the patient. Lastly, a biopsy
should not be performed if it could potentially put the success of a definitive procedure at risk. For example, an
incisional biopsy of a primary lung tumor or mass on the spleen may contaminate the entire chest or abdominal
cavity with tumor cells; therefore, primary lung tumors or masses on the spleen are usually removed and biopsied
with one definitive surgery as an excisional biopsy. Note that diffusely enlarged spleens are most often caused by
lymphoma or mast cell tumor and are often diagnosed by trans-abdominal fine needle aspiration cytology.
Biopsy as a Prelude to Definitive Therapy

Frequently quoted is the saying, “Our eyes are not microscopes.” A palpable, persistent mass is the most
1–3
common indication for biopsy as a prelude to definitive therapy. As accuracy and sensitivity of diagnostic tests
(such as ultrasound or CT/MRI) improves, biopsies are being performed with increasing frequency to also clarify the
diagnosis of visualized yet non-palpable masses.
When developing a diagnostic strategy for a cat with cancer, the clinician must consider the subsequent
3
management of the disease. Cats are often diagnosed with advanced disease that is frequently malignant and the
formulation of an appropriate diagnostic and therapeutic strategy early in the course of the disease is essential. The
first step in diagnosis of most palpable lesions is fine-needle aspiration cytology. If the cytologic diagnosis strongly
suggests a malignant condition or is highly suggestive of a particular condition (i.e. soft tissue sarcoma), a definitive
procedure such as surgical removal can be planned. In addition, this tentative diagnosis can begin to determine the
staging procedure ahead. Fine-needle aspiration cytology can also confirm the presence of a benign process,
eliminating the need for further diagnostic steps. If fine needle aspiration cytology is not definitive, then an incisional
biopsy should be performed, guided by or done by the surgeon who will perform the definitive surgery. Prior to a
biopsy procedure, there are standard diagnostics that can be performed in order to identify any concurrent disease or
clinically evident metastatic disease. Staging is accomplished by certain diagnostic tests that determine the extent of
the neoplastic disorder. The staging scheme differs for each neoplastic disease, but should include a complete blood
count, biochemical profile, urinalysis, FeLV and FIV serology, serum T4,thoracic radiographs, and cytologic
evaluation of regional lymph nodes. Discussions regarding additional diagnostic steps in specific staging schemes
are included in the chapters reviewing each individual disease.
Each biopsy should be performed with the assumption that the lesion is malignant. Therefore, the biopsy
should be done so that the entire surgical field, including all tissues or tissue planes that may have been disturbed,
Track A
and any post biopsy hemorage/hematoma can be removed by a subsequent surgery. Second surgeries performed
to remove the tumor and surrounding tissues frequently involve going at least one fascial layer below the tumor and
all tissues disturbed by the previous surgery.
Skin Biopsy
A skin biopsy is essential to diagnose and evaluate potentially malignant skin conditions. Punch, incisional,
1–3
excisional, and needle core biopsies are employed.
1–3
Punch Biopsy
Biopsy punches are available as re-useable, expensive instruments or disposable inexpensive units which
may be reused after appropriate sterilization until they become dull. They are available in diameters ranging from 2
mm to 6 mm Generally, taking a larger biopsy specimen is preferred so that the pathologist has an adequate sample
from which to make a histologic diagnosis. When possible, multiple samples at the junction between normal and
abnormal tissue should be biopsied. Punch biopsies are usually inadequate to obtain tissue below the dermis
because subcutaneous tissue is rarely obtained in the average punch biopsy of the skin.
Indication: Identification of any dermal or epidermal lesion of unknown etiology

Contraindications/Complications: Coagulopathies; lidocaine toxicities (unlikely)
Benefits: General anesthesia is not required; simple outpatient procedure
Limitation: Small tissue samples obtained may not be diagnostic
Equipment: Sedation and analgesia should be considered; 2% lidocaine and 8.4% bicarbonate (50:50); Baker’s
biopsy instrument; standard surgical instruments; suture material
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Technique:
1. Clip the hair and prepare the site with proper aseptic surgical technique.
2. 2% lidocaine will sting less upon injection if it is diluted 50:50 with 8.4% bicarbonate. Using a 25-ga needle,
approximately 1/4 to 1 ml of this local anesthetic agent is injected around the lesion. It is important to make
sure that injection of lidocaine does not distort or disturb the normal architecture of the tissue that is to be
biopsied.
3. The biopsy area is surgically scrubbed a final time after the lidocaine is injected.
4. Stretch the skin of the site to be biopsied between the thumb and index finger.
5. Place the biopsy punch instrument at a right angle to the skin surface.
6. Rotate the punch instrument in one direction and at the same time, apply firm downward pressure until the
subcutis is reached.
7. Angle the punch almost parallel with the skin while still applying pressure along the long axis of the
instrument.
8. Rotate the punch to sever at least part of the base of the biopsied tissue.
9. Remove the punch instrument and gently elevate the core of tissue with the point of a needle; sever the base
that is still attached with a scalpel blade or a pair of iris scissors.
10. Place one or two sutures as needed to close the defect, depending on the size of the punch taken.
Supportive Care: Oral analgesics; cleansing of the surgery site periodically. Consider the use of an E-collar to
prevent self-trauma.
1–3
Incisional Biopsy
In some cases, an incisional biopsy is preferred to a punch biopsy because larger sections of tissue can be
obtained for histologic diagnosis. In addition, if the lesion is biopsied at the junction of the normal and abnormal
tissue, a “wedge” of tissue is obtained that retains a larger section of the tissue’s architecture. This makes it easier
for the histopathologist to see characteristics of malignancy, such as invasion into the normal tissue.
Indication: Identification of dermal, epidermal, or subcutaneous lesion of unknown etiology

Contraindications: Coagulopathies; cats which are high risk for general anesthesia
Benefit: Larger tissue sample often results in a more accurate diagnosis
Limitations: General anesthesia is often needed; not a definitive procedure
Equipment: Sedation and general anesthesia; standard surgical instruments; suture material
Technique: Perform routine screening tests to identify problems such as coagulopathies and metabolic disease.
1. Place the cat under general anesthesia.
2. Surgically prepare the area with clipping and strict aseptic technique, then properly drape the site. An
elliptical or wedge incision is made at the margin of normal and abnormal tissue. Care is taken to obtain
adequate tissue and to ensure that a subsequent definitive surgery can remove the tumor and the incisional
biopsy area successfully.
3. Vessels going to and from the tissue to be biopsied are carefully identified and ligated.
Track A
4. The specimen is lifted and severed at the base with either scissors or a scalpel blade.
5. The incision is sutured for closure.
Supportive Care: Oral or parenteral analgesics for several days to weeks; cleansing of the surgery site periodically
1–3
Excisional Biopsy
An excisional biopsy should be performed for a histologic diagnosis on a lesion that is small and located in
an anatomic location where wide surgical removal is possible and yet will not compromise the normal tissue around it
(e.g., cutaneous, basal cell tumor on the lateral abdominal wall <0.5 cm in diameter). In nearly all cats, an excisional
biopsy is preceded by fine-needle aspiration cytology and/or incisional biopsy to give the surgeon as much
information as possible about the characteristics of the tumor prior to removal. For example, a vaccine-associated
sarcoma requires wide surgical margins (2 to 3 cm), whereas a benign basal cell tumor can be excised with smaller
margins.
Indication: Identification of dermal, epidermal, or subcutaneous lesion of unknown etiology

Benefit: Larger tissue sample often results in a more accurate diagnosis
Limitation: Requires general anesthesia. May make definitive second procedure more difficult to achieve.
Technique: This biopsy is performed in the same manner as an incisional biopsy except the lesion is excised
completely, with adequate margins.
Supportive Care: Oral or parenteral analgesics for days to weeks; cleansing of the surgery site periodically
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Needle Core Biopsy
Needle core biopsy generally is safe and quick and can be performed on an awake, cooperative cat as an
1
outpatient when appropriate analgesia and sedation are used. Unless medically contraindicated, analgesics are
used prior to and after the biopsy. Histopathology results, generally, are more accurate than those of fine-needle
aspiration cytology but are not as accurate as the results of an excisional or incisional biopsy due to the size of tissue
sample obtained. Needle core biopsy instruments, especially the spring-loaded models that can be adjusted to obtain
tissue from different depths, are preferred.
Indication: Identification of a skin or subcutaneous lesion of unexplained etiology

Contraindications/Complications: Coagulopathies; lidocaine toxicity (unlikely)
Benefit: General anesthesia is not required, so the procedure can be performed on an outpatient basis
Limitation: The small tissue samples that are obtained may not be diagnostic
Equipment: Sedation and analgesia should be considered; No. 11 surgical blade; 2% lidocaine; needle biopsy
instrument
Technique:
1. The cutaneous or subcutaneous lesion is grasped by an assistant and immobilized, and the biopsy site is
prepared with surgical scrub for an aseptic procedure.
2. Approximately 1/4 to 1 ml of 2% lidocaine is injected around the lesion to be biopsied while trying not to
disturb the architecture of the tissue to be evaluated with the lidocaine. The lidocaine will sting less upon
injection if diluted 50:50 with 8.4% bicarbonate.
3. Using a No. 11 surgical blade, a stab incision is made in the skin to allow easy entry of the needle core
biopsy instrument.
4. The needle core biopsy instrument is advanced through the incision to the outer portion of the lesion to be
biopsied. In the case of the skin, the instrument is just advanced into the tissue to be biopsied.
5. Three to five biopsy specimens are taken from the suspect tissue through the same stab incision. This will
allow the histopathologist to evaluate a sample of tissue from various portions of the mass, enhancing the
probability of making an accurate diagnosis. These indvidual biopsies are best obtained by redirecting the
needle within the mass.
6. The needle biopsy specimens are fixed in 10% buffered formalin, as described previously. A separate
container should be used for each lesion that is biopsied and labeled accordingly.
7. The stab incision is sutured only if indicated by the size and depth.
Supportive Care: Oral analgesics for several days; cleansing of the surgery site periodically
Lymph Node Biopsy

Lymph node biopsy is often important in the diagnosis, staging, and proper therapeutic management of the
1–3
cat with cancer. Excisional or needle core biopsy is often performed after fine-needle aspiration cytology suggests
the presence of disease. Despite the accuracy of fine-needle aspiration cytology in determining the presence of
diseases such as lymphoma or metastatic solid tumors, a histopathologic diagnosis is always recommended prior to
Track A
initiation of therapy. A completely excised lymph node will allow the histopathologist to assess subtle architectural
changes that are not always present in tissue obtained by needle core biopsy. In each case, adequate tissue must be
obtained for histopathologic diagnosis and for special stains, if indicated. If other lymph nodes are enlarged, the
submandibular lymph nodes should be avoided; they often are reactive in the normal cat because they drain the oral
cavity, where the bacterial count is usually quite high. These reactive cells are sometimes misdiagnosed as
neoplastic cells. Whenever a malignancy is suspected, the biopsy should be planned so that the entire biopsy “tract”
can be removed by the definitive surgery. This is because the biopsy procedure can “seed” the operative field with
tumor cells if the principle of en bloc dissection is violated. As with all biopsies, the surgeon who will perform the
definitive surgery should be consulted prior to the biopsy to ensure that incisions are properly placed for a
subsequent definitive procedure.
Lymph Node Excision

The type of biopsy done on the lymph node will depend on each case; however, an excisional biopsy should
1–3
be performed when possible because this allows the pathologist to determine the architecture of the entire lymph
node and to determine whether capsular invasion exists. This is especially valuable in cats, where lymphoma must
be differentiated from lymph node hyperplasia.
Lymph node excisions are performed commonly in cats that have lymphadenopathy, especially when
lymphoma or other malignant conditions are suspected. A lymph node that is not easily seen or palpated by the
casual observer should not be considered for removal. Hair should be clipped prior to surgery; however, the amount
of hair clipped should not be excessive, because cats on chemotherapy often have slow hair re-growth in clipped
areas. In addition, anti-neoplastic agents can cause alopecia, which makes the surgical site cosmetically noticeable
for weeks to months after the procedure.
215
Indication: Lymphadenopathy of unexplained etiology
Contraindications: Coagulopathies; cats who are high risk for complications due to anesthesia
Benefit: An accurate histopathologic diagnosis can be obtained because the entire lymph node architecture is
present
Limitation: Requires general anesthesia
Technique:
1. The cat is placed under general anesthesia after routine screening tests are performed to identify problems
such as coagulopathies and metabolic disease.
2. The hair is clipped, and the surgical site is prepared with proper aseptic technique.
3. After the region is draped, an incision is made over the enlarged lymph node.
4. Care is taken to identify and ligate the vessels going to and from the lymph node to be excised.
5. After the lymph node is removed, subcutaneous tissue is closed with absorbable suture, and the skin is
closed with either absorbable or non-absorbable suture.
Supportive Care: Oral or parenteral analgesics for days to weeks; cleansing of the surgery site periodically
Select Respiratory Tract Biopsy

2–4
Transthoracic Aspirate
Transthoracic aspiration cytology and thoracocentesis are procedures to remove or sample pleural fluid or
tissue within the lung for diagnostic or therapeutic reasons. Fluoroscopy and occasionally ultrasonography are
generally used to guide the biopsy of pulmonary, parenchymal, pleural, and mediastinal lesions. Ultrasonography is
effective when the tissue to be examined is surrounded by either fluid or other tissue, but not if surrounded by air. In
those cases that cannot be defined clearly by fluoroscopy or ultrasonography, computerized tomography imaging
(CT) or magnetic resonance imaging (MRI) can be used to guide tissue sampling. In one study of human patients
that included over 400 percutaneously biopsied pulmonary lesions, the accuracy of the procedure was determined to
4
be 96.5%. Ultrasound guided fine needle aspiration or blind aspiration were successful in obtaining diagnostic
samples from 20 of 25 cats in one series. Fluoroscopic or CT guided aspiration may be the most accurate for small
or less peripheral lesions.
Indications: Investigation of any masses, lesions, or fluid accumulations within or around the pulmonary
parenchyma that are not near or associated with the heart or blood vessels
Contraindications/Complications: Coagulopathies, poor pulmonary reserve, and pulmonary arterial hypertension;
complications are rare, less than 10%, but include hemothorax and pneumothorax; placement of a chest tube may be
required to resolve these problems.
Benefit: Cells or fluid can be acquired with limited risk and without a thoracotomy
Limitations: Requires general anesthesia or tranquilization; may cause pneumothorax or hemothorax
Equipment: 2% lidocaine; 3- to 12-ml syringe; 22-ga 1.5-inch needle
Technique:
Track A
1. After routine screening tests have been performed to identify problems such as coagulopathies, metabolic
disease, or organ failure, the cat is placed under general anesthesia or tranquilized.
2. The lesions are identified with fluoroscopy, ultrasonography, or computerized tomographic imaging. The hair
is clipped, and the site is prepared with a surgical scrub and aseptic technique. A surgical drape is placed to
enhance sterility.
3. If tranquilization is used instead of general anesthesia then the skin and underlying tissue, up to the pleura,
are anesthetized with 2% lidocaine (1/2-1 ml) that has been diluted with 8.4% bicarbonate at a ratio of 50:50.
4. A 22-ga needle attached to a 3- to 12-ml syringe is advanced through the skin and intercostal muscles. This
can be done “blind” but is best done using additional imaging techniques such as a fluoroscope,
ultrasonography, or computerized tomography (CT). Care is taken to avoid the heart and great vessels.
Pneumothorax is always a potential complication, but is not commonly a major concern if appropriate care is
taken during the procedure. If fluid is to be sampled, a three-way stopcock is attached between the syringe
and needle to facilitate removal of large amounts of fluid.
5. Tissue is aspirated while the needle is advanced through the lesion. To prevent injury of normal lung tissue,
the needle is inserted and the mass aspirated over a relatively short period. The pressure is eliminated prior
to removing the needle from the mass and chest cavity to prevent aspirating the acquired cells into the
syringe where they may be unrecoverable. The syringe is then removed from the needle and filled with air.
After the needle is re-attached to the syringe, the material in the needle is forcefully expelled onto a clean
microscope slide. If indicated, the material is gently spread over the slide to obtain a single layer of cells for
subsequent analysis. If fluid or sufficient tissue is removed, slides are made, and fluid is saved for culture
and sensitivity. The remaining fluid is saved in two tubes, an EDTA tube and a red top tube without
anticoagulant, for subsequent submission to a clinical pathologist for analysis.
216
6. The cat is watched carefully for respiratory difficulty for several hours. Ideally, a chest radiograph is taken to
insure that hemothorax or pneumothorax has not developed after the procedure. In addition the cat should
be rested for 24 to 48 hours.
Supportive Care: Monitor respiration for hours to days; oral analgesics as indicated
1,4
Nasal Biopsy
A nasal biopsy should be considered for every cat with a facial deformity, unilateral or bilateral epistaxis, or
epiphora of unknown etiology. A nasal tumor, rhinitis of either fungal viral or bacterial origin must be suspected in
many of these cases. A biopsy is required in each case before appropriate therapy can be recommended. Suspect
tumors in cats can be biopsied using equipment that is relatively inexpensive and quite effective. Although fiber optic
examinations and nasal flushes are valuable in some cases, they are not as rewarding as biopsy cup or curette
techniques. Regardless of the procedure, general anesthesia is required for all cats. Each cat should be biopsied
through the external nares to reduce surgical exposure through the skin, which could contaminate these structures
with tumor cells from the nasal cavity. Biopsy of nasal tumors frequently involves the use of a bone curette or a
relatively small “cup” biopsy instrument. Although biopsy through a bronchoscope or a cystoscope is relatively easy
to accomplish, the size of the tissue sample obtained through these instruments often is inadequate for an accurate
diagnosis. In part, this is because the tissue removed by these methods is superficial and the underlying true
pathology frequently is obscured by septic inflammation. Note, however, that a bronchoscope is ideal for identifying
lesions in the trachea. In addition, the bronchoscope can be retroflexed to peer rostrad over the soft palate to clearly
visualize the caudal nasal airways.
Indication: Examination of any undiagnosed nasal problem, especially when the cat has epiphora and epistaxis
and/or facial deformity
Benefit: The large tissue sample that can be obtained lends to more accurate diagnosis
Limitation: Requires general anesthesia.
Equipment: Sedation and general anesthesia; small to medium sized bone curette or “cup biopsy instrument
Technique: The cat is placed under general anesthesia after routine screening tests have been performed to identify
clinical problems, such as coagulopathies, metabolic disease, or organ failure.
1. The nasal lesion is identified with skull radiographs or preferably computerized tomography (CT) imaging.
The most valuable skull radiograph is an intra-oral exposure, which is best made with non-screen film placed
inside the mouth which allows imaging of the caudal aspect of the nasal cavity. General anesthesia is
required for this procedure.
2. One to 1/2 ml of 2% lidocaine, diluted 50:50 with 8.4% bicarbonate, can be flushed up into the biopsy site by
placing a tomcat or soft catheter, without the needle, through the nasal passage to the level of the lesion.
This may reduce local discomfort and allow a lighter plane of anesthesia.
3. Before each biopsy it is essential to “pre-measure” from the nares to the medial canthus of the eye. The
largest bone currette that can be passed up the opening of the nasal cavity should be measured and marked
Track A
with tape or a marking pen. The currette is used to scoop or scrape the tumor into the instrument before it is
removed from the nasal cavity. Small biopsy “cup” instruments can be used to pinch off portions of the tumor.
The tumor, should be placed into formalin for subsequent analysis.
4. Mild to moderate hemorrhage is expected and will subside within a relatively short period. If hemorrhage is
excessive, ipsilateral carotid artery ligation should assist in reducing the bleeding. Hematocrit levels should
be monitored hourly until all bleeding has stopped.
Supportive Care: Clean nose free of any crusting, dried material or moist exudates; provide oral or parenteral
analgesics for days to weeks as needed
Selection of an Endoscope
The endoscope should:
1. have an instrument port and channel
2. at a minimum be bi-directional
3. bend more than 100 degrees in at least one direction
4. have an external light source
Instruments that should be available for the endoscope and that can pass through the instrument port are:
cytology brushes, biopsy forceps and graspers. Adult or pediatric endoscopes (5 mm in diameter) can be inserted
into the trachea of cats.
Bone Marrow Aspiration and Biopsy

Bone marrow aspiration and biopsy are essential procedures for determining cytologic and histologic
abnormalities of the bone marrow caused by a wide variety of neoplastic, infectious, and myelodysplastic
217
1–3
conditions. A bone marrow aspirate and biopsy are indicated when an abnormality in the production of blood cells
is suspected or when attempting to stage a cat with a hematopoetic malignancy.
1–3
Bone marrow aspiration is performed to acquire a monolayer of cells for individual evaluation. Aspiration is
therefore good for evaluating the cytology of the bone marrow versus the undisturbed architecture, which can be
examined when a bone marrow biopsy is performed. In order to identify a wide variety of malignant and
nonmalignant disorders, Romanovsky (including Wright’s and Giemsa) stains are preferred. When the cytologic
diagnosis of a cell type is not certain, additional special stains, including myeloperoxidase, Sudan black, and periodic
acid-Schiff, can be used. Bone marrow biopsies are beneficial for determining bone marrow cellularity, the presence
and extent of fibrosis or granulomatous conditions, and the presence of nonhematopoetic malignancies.
Indications: Blood cell production abnormality; staging procedure for a hematopoetic or non-hematopoetic
malignancy
Contraindications: Coagulopathies
Benefits: Aspiration can provide a sample for individual cell analysis, whereas a biopsy can provide tissue to
analyze cellularity, architecture, and content. Often, this can be done using local anesthesia, with systemic analgesia
and/or tranquilization/
Limitation: A single sample may not be representative of the entire bone marrow
Equipment: No. 11 surgical blade; 2% lidocaine; 6- to 12 ml-syringe; 18 ga. Illinois or Rosenthal bone marrow
needle microscope slides; EDTA container. Sedation or anesthesia is preferred with a local anesthesia.
1-3
Technique:
1. The hair is clipped, the microscope slides are cleaned and made ready for the sample to be processed, as it
will clot quickly, and the bone marrow aspiration site is prepared with a surgical scrub. Preferred sites and
positioning in the cat include:
o dorsocranial or lateral aspects of iliac crest (cat is in sternal or lateral recumbency)
o greater trochanter of the femur (cat is in lateral recumbency)
o greater tubercle of the proximal aspect of the head of the humerus (cat is in lateral recumbency)
2. Using a 25-ga needle, approximately 1/2 to 1 ml of the local anesthetic agent, lidocaine (2%), is injected in
and around the site where the bone marrow needle is to be introduced. Care is taken to inject lidocaine (2%)
in and around all of the tissues that extend from the skin to the periosteum. The lidocaine will sting less upon
injection if it is diluted 50:50 with 8.4% bicarbonate.
3. The biopsy area is scrubbed one more time after the lidocaine injection. A surgical drape should be applied
for sterility.
4. The bone marrow site is identified, the skin is stretched between the thumb and index finger, and a small
stab incision is made with a No. 11 surgical blade in the area blocked with lidocaine.
5. The bone marrow needle, with the stylet in place, is advanced into the stab incision and through the skin,
subcutaneous tissue, and muscle all the way to the bone. It is crucial to keep the stylet in place because it
has a tendency to back out during the procedure. An 18 ga. Illinois or Rosenthal needle is preferred for most
cats. After a sample is obtained for cytologic evaluation, a 14 ga. Jamshidi (bone marrow biopsy instrument)
Track A
needle is used to collect a biopsy specimen, if required.

6. With the stylet in place, the bone marrow needle is advanced into the bone, using a corkscrew motion. The
instrument should not be allowed to wobble and should be fixed firmly into the bone like a nail that has been
securely hammered into wood. When the needle is firmly fixed within the bone, the stylet is removed and the
syringe is affixed. Many clinical pathologists suggest rinsing the syringe and bone marrow needle with EDTA
before the procedure to reduce clotting of the bone marrow sample. Heparin should never be used.
7. The bone marrow sample is aspirated briskly into the 6- to 12-ml syringe; usually, 1/2 to 1 ml of marrow is
adequate. The aspiration may be accompanied by a few seconds of pain, but this can be prevented by the
use of oral or parenteral analgesics such as fentanyl, butorphanol, morphine, carprofen, or other analgesics.
8. If a sample is not obtained, the stylet is replaced in the bone marrow needle, and the instrument is then
advanced further into the bone for a second attempt at aspirating marrow. Once marrow has been obtained,
smears are prepared. This can be done in a number of ways:
o The marrow and blood are expelled into a small Petri dish that contains a few drops of EDTA.. The
marrow-rich spicules are placed on a slide or cover slip and then spread between slides or cover
slips to make a monolayer of cells Make sure the slides have been cleaned and are ready for the
sample to be processed, as it will clot quickly.
o A portion of the marrow sample is placed on the proximal portion of the slide; the slide is tipped
downward to allow the blood to run down and off the slide. The spicules and heavier nucleated cells
do not run off and are used for subsequent slide preparation.
o Marrow can be spread into a monolayer like a routine blood smear.
o The first two methods may enhance the ability to evaluate the nucleated cell population of the bone
marrow specimen.
218
A biopsy of a bone lesion or the bone marrow can be obtained with the Jamshidi (bone marrow biopsy
instrument) needle or the bone marrow needle after aspiration is performed. For biopsy, the stylet is removed. After
the aspiration, the instrument is advanced as described earlier. The needle is then rocked back and forth in two
o
directions at 90 to each other. In humans, pre-medication usually is not necessary if local anesthesia is adequate,
because pain is usually minimal. The purpose of the rocking movement is to sever the bone in the needle from its
base. The biopsy instrument is then removed, and a smaller wire obturator is used to retrograde the biopsy piece out
of the top end of the biopsy instrument. Cytology and histopathology can then be performed on this tissue. Direct
pressure should be applied to the site for several minutes to prevent hematoma formation. The small incision may
be sutured or glued closed.
Supportive Care: Oral or parenteral analgesics for hours to days may be indicated
Lower Urogenital Tract Biopsy

Biopsies of the lower urogenital tract are common procedures for the practitioner. Bladder tumors can be
1,2
biopsied by laparotomy or with a less invasive procedure, such as using cystoscopy. Pediatric bronchoscopes, rigid
cystoscopes or arthroscopes of the smallest size, are the only instruments suitable for cystoscopy in cats (see later
text). The prostate, while rarely sampled, is usually biopsied via laparotomy, although it can be biopsied
1,2
percutaneously, especially when guided with concurrent imaging. Testicular biopsies can be performed by
1
castration, or rarely through fine-needle aspiration cytology.
Biopsy of the Bladder

Cats with micro- or gross hematuria, with or without stranguria and dysuria, that is not resolving with
1,2
antibiotic therapy must be evaluated for a bladder tumor. Transitional cell carcinoma, although relatively
uncommon, is the most common bladder tumor in cats. Other differentials causing the above listed clinical signs,
including uroliths, must be ruled out. In each case, a biopsy is required to make an appropriate diagnosis. Prior to the
biopsy, a double-contrast cystogram and/or bladder ultrasonography is essential to localize and characterize the
lesion. The most common methods for nonsurgical biopsy of the bladder are cystoscopy with a rigid or flexible fiber
optic endoscope. A more practical and less expensive method is to use an open-ended urinary catheter that is
advanced against the tumor; the tumor is vigorously aspirated into the catheter and the entire instrument is then
retracted, hopefully with a piece of tumor held within the catheter lumen.
Catheter Biopsy of the Bladder

Indication: Any undiagnosed persistent bladder problem, especially when the cat has cystitis or hematuria, which is
unresponsive to standard therapy
Contraindications/Complications: Coagulopathies; cats which are high risk for general anesthesia; this technique
is more challenging in female cats
Benefit: Tissue samples can be obtained without surgery and often result in an accurate diagnosis. No risk of
tracking tumor cells through the abdomen.
Limitations: Requires general anesthesia
Track A
Equipment: 12-ml syringe and open-ended tomcat urinary catheter; general anesthesia is preferred
Technique:
1. After routine screening tests have been performed to identify problems such as coagulopathies, metabolic
disease, or organ failure, the cat is placed under general anesthesia.
2. The bladder or urethral lesion is identified with ultrasonography or a double-contrast cystogram.
3. The catheter should be “pre-measured” so the length to be advanced does not exceed the measurement
from the area of the distal urethra to the level of the tumor, which generally is not further forward than the
caudal two mammary glands. This precaution reduces the risk of bladder perforation.
4. The open-ended tomcat catheter is advanced through the urethra and then forcefully into the tumor. This is
best accomplished with ultrasonographic or fluoroscopic guidance or by palpating the mass per abdomen.
5. Once the tumor has been entered, suction is applied while the instrument is withdrawn. Tissue that has been
suctioned up into the catheter and torn off during removal of the catheter is expelled and placed in 10%
formalin for subsequent fixation and analysis.If impression smears are desired for cytology, those should be
taken before the tissue is formalinized. Note that formalin fumes will alter cytologic characteristics.
Supportive Care: Oral analgesics may be needed
Digestive System Biopsy

Surgical exploration and biopsy remains the most complete method of exploring the digestive system in the
cat. The oral cavity is readily accessible; however, planning of correct placement of the surgical biopsy tract is critical
for long term care of the cat with cancer. The biopsy is crucial not only to obtain a definitive diagnosis but also to
ensure that definitive surgery can be performed subsequently with minimal cosmetic and functional alterations to the
1
cat. Surgical exploration of the abdomen and chest is more invasive than fiberoptic endoscopy and may be
associated with greater risks. Although exploratory surgery has many benefits, endoscopic examination of the
219
gastrointestinal (GI) tract is a common, effective, low-risk means of diagnosing malignant conditions of this organ
1–5
system. In addition, with endoscopy, benign conditions that mimic malignancy can be identified for subsequent
1,5
treatment. Flexible fiberoptic endoscopes can be used to examine all areas of the esophagus, stomach, proximal
duodenum, rectum, and colon. Rigid endoscopes or proctoscopes can be used to examine portions of the
esophagus, rectum, and most of the descending colon. Laparoscopy has the advantage of evaluating many organs
of the abdomen with very little trauma to the cat. The techniques of oral biopsy, upper and lower GI endoscopy, and
abdominal laparoscopy will be discussed separately.
3
Biopsy of the Oral Cavity
Biopsy of an oral cavity lesion is essential because almost all of the tumors in this area have different
prognoses and treatments, despite similar gross appearances. Before any oral lesion is biopsied, radiographs should
be taken to determine the presence of bone invasion. This is essential information for the pathologist and the
surgeon. For example, a pathologist would consider a diagnosis of a low-grade fibrosarcoma rather than a fibroma if
radiographs suggested the presence of bone involvement, despite the fact that the biopsy finding was consistent with
a gdiagnosis of fibroma. Similarly, a mandibulectomy or a maxillectomy would be the surgical approach if bone were
involved. Whenever a tooth is removed in a cat, a biopsy should be considered to rule out the presence of cancer as
an underlying cause. Before a biopsy is planned, the surgeon who will perform the definitive procedure should be
consulted to ensure that the biopsy does not compromise the success of the procedure or the health of the cat. If the
biopsy involves tissues that are essential for closure or if the tumor is seeded into an area that is too large to resect,
a successful outcome of the definitive procedure may be prevented. Although an excisional biopsy is an option, an
incisional biopsy is more frequently performed to guide the decision for a definitive procedure.
Indication: Identification of an oral mass of unexplained etiology

Benefit: An accurate histopathologic evaluation can be obtained because part or all of the oral mass can be sampled
Equipment: General anesthesia standard surgical instruments
Technique:
1. After routine screening tests have been performed to identify problems such as coagulopathies and
metabolic disease, the cat is placed under general anesthesia. An endotracheal tube with a properly fitting
cuff is placed and secured to prevent aspiration of blood or other oral contents.
2. The oral mass is radiographed. When possible, intra-oral radiographs should be acquired in addition to other
views. More specific details regarding this technique are outlined in the chapter on Tumors of the
Gastrointestinal Tract.
3. After a nerve block is placed and/or parenteral analgesics are started, an incision is made over the oral
mass, and a section of the lesion is taken at the junction of normal and abnormal tissue. Care is taken not to
biopsy through normal lip or skin, as this may be needed for reconstructive surgical techniques. Options
include excisional or incisional biopsy procedures.
4. Any bleeding that occurs is stopped with ligation, cautery, or in the case of an open bone biopsy, bone wax.
Track A
Bleeding usually subsides within 5 to 10 minutes.

5. After the oral mass is removed, surrounding tissue is sutured if possible. Keep in mind that the oral cavity is
a contaminated area.
6. The oral tumor should then be adequately fixed in 10% formalin.
Supportive Care: Oral or parenteral analgesics may be indicated and soft food should be offered for a period of
days
References
1. Ogilvie GK, Moore AS: Managing the Veterinary Cancer Patient: A Practice Manual. Veterinary Learning
Systems, 1995, pp 1-47.
2. Withrow SJ, MacEwen EG: Small Animal Clinical Oncology. Philadelphia, WB Saunders, 1996, pp 52-57.
3. Morrison WB, Hamilton TA, Hahn KA, et al: Diagnosis of neoplasia, in Slatter D (ed): Textbook of Small
Animal Surgery, ed 2. Philadelphia, WB Saunders, 1993, pp 2036–2048.
4. Wolmark N: Biopsy as a prelude to a definitive operative therapy for breast cancer, in Wittes RE (ed): Manual
of Oncologic Therapeutics 1991/1992. Philadelphia, JB Lippincott, 1991, pp 5–8.
Systems, 1995, pp 1-47.
7. Sober AJ: Skin biopsy in the diagnosis and management of malignancy, in Wittes RE (ed): Manual of
Oncologic Therapeutics 1991/1992. Philadelphia, JB Lippincott, 1991, pp 1–5.
Systems, 1995, pp 1-47.
220
10. Avis F: Lymph node biopsy, in Wittes RE (ed): Manual of Oncologic Therapeutics 1991/1992. Philadelphia,
JB Lippincott, 1991, pp 8–9.
Systems, 1995, pp 1-47.
13. Martini N: Diagnostic procedures relating to the thorax, in Wittes RE (ed): Manual of Oncologic Therapeutics
1991/1992. Philadelphia, JB Lippincott, 1991, pp 9–10.
14. Westcott JL: Direct percutaneous needle aspiration of localized pulmonary lesions: Results in 422 patients.
Radiology 137:31–35, 1985.
15. Withrow SJ: Diseases of the respiratory system, in Withrow SJ, MacEwen EG (eds): Clinical Veterinary
Oncology. Philadelphia, JB Lippincott, 1989, pp 215–233.
16. Hahn KA, McEntee MF: Primary lung tumors in cats: 86 cases (1979-1994). JAVMA 211:1257-1260, 1997.
Systems, 1995, pp 1-47.
19. Lee EJ, Schiffer CA: Bone marrow aspiration and biopsy, in Wittes RE (ed): Manual of Oncologic
Therapeutics 1991/1992. Philadelphia, JB Lippincott, 1991, pp 24–26.
Systems. 1995, pp 1-47.
22. Ogilvie GK, Moore AS: Digestive System Biopsy, in Managing the Veterinary Cancer Patient: A Practice
Manual. Trenton, NJ, Veterinary Learning Systems Co., Inc, 1995, pp 29-36.
23. Lightdale CJ: Liver biopsy, in Wittes RE (ed): Manual of Oncologic Therapeutics 1991/1992. Philadelphia, JB
Lippincott, 1991, pp 20–22.
24. Jones BD, Hitt M, Hurst T: Hepatic biopsy. Vet Clin North Am Small Anim Pract 15:39–64, 1985.
25. Withrow SJ: Biopsy principles, in Withrow SJ, MacEwen EG (eds): Clinical Veterinary Oncology.
26. Lightdale CJ: Upper gastrointestinal endoscopy, in Wittes RE (ed): Manual of Oncologic Therapeutics
1991/1992. Philadelphia, JB Lippincott, 1991, pp 14–15.
27. Penninck DG, Nyland TG, Kerr LY, Fisher PE: Ultrasonographic evaluation of gastrointestinal diseases in
small animals. Vet.Radiol. 1990;31:134-141.
28. Penninck DG, Crystal MA, Matz ME, Pearson SH: The technique of percutaneous ultrasound guided fine-
needle aspiration biopsy and automated microcore biopsy in small animal gastrointestinal diseases.
Track A
Vet.Radiol.Ultrasound 1993;34:433-436.
29. Crystal MA, Pennick DG, Matz ME, Pearson SH, Freden GO, Jakowski RM: Use of ultrasound-guided fine-
needle aspiration biopsy and automated core bipsy for the diagnosis of gastrointestinal diseases in small
animals. Vet. Radiol. 1993;34:438-444
30. Münster M: Effizienz der endoskopie bei magen-darm-erkrankungen von hund und katze. Der Praktische
Tierarzt 1993;4:309-312.
Systems, 1995, pp 1-47.
33. Sober AJ: Skin biopsy in the diagnosis and management of malignancy, in Wittes RE (ed): Manual of
Oncologic Therapeutics 1991/1992. Philadelphia, JB Lippincott, 1991, pp 1–5.
NOTES:
221
NOTES:
Track A
222
Injection Site Associated and Other Soft Tissue Sarcomas: New Advances for 2015
Incidence, Signalment, and Etiology

Soft tissue sarcomas are grouped together in this document because of apparent similarities in their biologic,
and therefore clinical, behavior. Some may be caused by inflammation or injections. A brief, separate discussion of
this entity is below. The reality is that regardless of the cause, they have similar characteristics and are thus
discussed as such. Benign variants of these tumors are reported (e.g., fibroma, rhabdomyoma, etc.), but it is best to
think of them as highly locally invasive, low grade malignancies and to treat them in the same aggressive manner as
tumors described as sarcomas.
Fibrosarcoma is the most common histologic diagnosis within this group of tumors. Histologic distinction may
be difficult with other tumors. For example, confirmation of muscle origin (rhabdomyosarcoma) requires
1,2
immunohistochemical staining for the intermediate filament desmin, and histologic differentiation of
3
neurofibrosarcoma from Schwannoma is possible only by using electron microscopy or by identifying small bundles
4,5
and palisades of cells called Antoni type A pattern. Soft tissue sarcomas with a highly mucinous stroma are called
6
myxofibrosarcomas or myxosarcomas.
6,7
Two large studies totaling 712 cats are the source of epidemiologic data on soft tissue sarcomas. One
study of cats in the United States showed that DSH cats were nearly twice as likely as other breeds to develop
6 7
fibrosarcomas. In contrast, a German study showed no evidence of breed predispositions.
The ages of affected cats ranged from 1 to 18 years, and there appears to be incidence peaks at 3 and 8
7
years of age. Recent U.S. studies have shown an increased risk for young cats to develop injection site sarcomas
7
(discussed below); however, the German study cited above also showed a young age peak in cats diagnosed
between 1970 and 1984, which is prior to changes in vaccination habits. Another explanation for the increased risk in
young cats is the presence of feline sarcoma virus (FeSV; discussed below). These cats often have multiple tumors,
7
as was the case in 10 of 174 cats (5.8%) in one of the two studies cited above and 7 of 494 cats (1.4%) in the
6 7
other. Affected cats were between 3 and 7 years of age. There was no obvious gender predilection in either study.
7
In one study, 58% of tumors affected the hindquarters and 39% affected the thorax. More specific site
6
distribution was provided for 494 cats : 28 tumors (26%) were on the head and neck, 196 (40%) on the limbs, 52
(10.5%) on the back, 42 (8.5%) on the thorax, 56 (11%) on the abdomen, 12 (2%) on the tail (2%), and 1 each
(0.2%) on the perineum and scrotum.
Other specific site distributions have been noted. Four cats with rhabdomyoma of the pinna were described.
8
Three of the cats were white, and all four cats had white pinnae. Myxosarcomas occurred most commonly on the
6
limbs (16 of 23 tumors) in one study.
There has been interest in chromosomal aberrations associated with soft tissue sarcoma, particularly those
Track A
9
occurring at injection sites. A neurofibroma on the flank of a cat showed a trisomy of chromosome D2, and a
10 11
fibrosarcoma showed multiple copies of many chromosomes. Other chromosomal aberrations have been noted.
Further information is included in the section on injection site sarcomas. Mutations in the tumor suppressor gene,
12,13
p53, have also been identified in feline soft tissue sarcomas but may not be specific to injection site
14,15
sarcomas.
Clinical Presentation and History

Soft tissue sarcomas are often dermal in origin, so the most common reason for presentation is a mass that
7
the owner detected while grooming or petting the cat. Tumors can vary in size from 0.3 to 15 cm in diameter and are
typically not well demarcated. Ulceration is rare but may occur secondary to pressure necrosis of the skin overlying
7
large tumors. Most tumors are firm, although some may be cystic or mucinous, which can make them feel soft. Soft
tissue sarcomas can be slow to enlarge, and owners may delay seeking veterinary advice for years after first
4,16–19
detecting a mass. Tumors that infiltrate the underlying bone may cause lameness, and those arising from the
20–22
nerve sheath may cause weakness and pain.
Staging and Diagnosis

Soft tissue sarcomas infiltrate far beyond the clinically palpable borders, and those affecting the nerve sheath
22,23
may extend through bone to involve the spinal dura. Therefore wide surgical excision is needed to ensure
adequate tissue margins are obtained, and adjunctive radiation therapy is often necessary. A CT scan prior to
surgery or radiation therapy will allow delineation of tumor margins and allow for all treatment options to be explored.
MRI, if available, will also allow detailed examination of the tumor margins prior to treatment.
Metastasis appears to be uncommon, regardless of the subtype of soft tissue sarcoma. In one study, 8 of 84
7
cats (10%) had confirmed metastases and another 12 had suspected but unconfirmed metastases (24%). In other
19,24–27
studies, 32 of 158 cats (20.3%) had metastases. Some investigators believe that the metastatic rate for
223
injection-site sarcomas may be higher than for sarcomas affecting other sites. It is difficult to estimate the overall rate
of metastasis because many older studies relied on surgical excision alone to control the tumor and most cats died
as a result of local recurrence soon after surgery. Although metastases have been reported as soon as 5 weeks after
19,28 25,26
surgery, they are usually detected much later. Recent studies encompassing cats with injection site sarcomas
have included cats treated with radical surgical procedures and often adjunctive therapies such as radiation therapy.
In these studies, local tumor control has improved, which may in turn increase the chances for occurrence, and
therefore detection, of metastases.
1,7,25,26,28
Metastases have most often been described to the lung, with occasional concurrent skin
26,28 7 1,7
metastases. Splenic metastases have been reported, as has renal involvement. Regional lymph node
7,25,26,28
involvement appears to be uncommon, occurring in only 3 of 108 cats. Thoracic radiographs do not usually
19,26
disclose evidence of metastasis at the time of presentation but they should still be included as part of the MDB in
staging procedures. Although lymph node involvement is uncommon, nodes should be palpated and fine-needle
aspiration for cytologic evaluation performed if they are enlarged. Splenic metastases have been reported, albeit
rarely, and thus abdominal ultrasonography is important for completeness of staging.
A preoperative biopsy is recommended to guide therapy. Radiation therapy prior to surgical excision may
have advantages over postsurgical radiation (see the Treatment section). To reduce the size of the surgical scar that
would need to be irradiated, an incisional or Tru-cut needle biopsy is preferred over an excisional biopsy. The degree
of histologic differentiation and mitotic rate found on biopsy may be prognostic. In one study of 174 sarcomas, 91
(52%) were characterized as fibrosarcomas, 57 (33%) as pleomorphic sarcomas, 22 (13%) as spindle cell sarcomas,
7
and 4 (2%) as undifferentiated. Of 8 cats that developed confirmed metastases, four had pleomorphic tumors, 2 had
7 29
fibrosarcomas, and 2 had spindle cell sarcomas. The mitotic index can vary widely in feline soft tissue sarcoma. In
30
one study, the mitotic index of the tumor predicted recurrence and survival following surgery. Nineteen cats with a
mitotic index of 4 or less had a median survival of 128 weeks despite a 63% recurrence rate. In contrast, 16 cats with
a mitotic index of 5 or greater survived a median of 16 weeks, and the recurrence rate was 75%.
Treatment
Surgery
Surgical excision has been the principal treatment modality for soft tissue sarcomas. Due to the extensive
infiltration and invasion of surrounding normal tissue, it is necessary to resect a wide and deep (more than 2 cm)
margin of normal tissue in all surgical planes around the palpable tumor. While this is often possible in larger species
such as dogs and humans, it is rarely possible in cats, particularly following an initial unsuccessful attempt.
Exceptions to this would be tumors on a distal limb or other extremity that can be amputated. For this reason the first
attempt at surgical removal should be the definitive one, and wide surgical margins that include bone, muscle, and
other structures should be obtained. For example, a cat with soft tissue sarcoma in the interscapular space would
require resection that encompasses 2 cm or greater circumferential margins of normal tissue, including the dorsal
process of the scapulae and dorsal spinous processes. The aim should be to remove the tissue “en bloc” without
incising tumor tissue itself.
The surgeon should be aware that as soft tissue sarcomas grow, they compress a cuff of tumor cells to form
Track A
a pseudocapsule, thereby giving the false impression that the sarcoma is encapsulated.
Because aggressive surgeries require specific surgical skills and adequate planning, the preferred approach
is an incisional or Tru-cut needle biopsy prior to consulting with an experienced surgeon and/or radiation oncologist.
As stated earlier, pretreatment staging should include a CT scan to more clearly define the tumor margins and areas
of infiltration.
In a study of 84 cats surgically treated for soft tissue sarcoma, 60 cats (70%) had tumor recurrence an
7
average of 3.5 months later. Tumors recurred as soon as 2.5 weeks and as long as 1.5 years after surgery. Only 34
of the 60 cats had a second surgery; the other 26 were euthanized. Of these 34 cats, 27 (80%) had a second
recurrence and 12 of these were euthanized. Of the 84 cats originally treated, only 9 cats became disease free and
7
only 4 of those were disease free longer than 18 months. A similar recurrence rate of over 80% was seen in another
31
study in which the median tumor free period following surgical excision was 4 months. Only 10% of 61 cats were
28
tumor free a year after surgery in another study ; these cats had all been treated by wide excision or amputation.
Tumors that involve the limb often recur after an attempted local excision, but the likelihood of long-term
4,16,19,27,28,30 8 32
control following amputation is high. Similarly, tumors of the pinnae or even nictitans may be removed
with complete surgical margins. For more extensive limb tumors that approach the pelvis, a hemipelvectomy may be
33
required; if complete margins cannot be obtained, a rapid recurrence should be expected. Procedures that are less
18
aggressive than amputation, such as scapulectomy, may leave tumor cells and lead to recurrence.
Aggressive surgical excisions in other areas may lead to long-term tumor control even after other methods
33
have failed. However, the first surgery should be considered definitive rather than relying on a second or third
surgery for salvage. Wide resection on the chest wall or flank may require rib or body wall removal and the use of
34
propylene mesh. Even with extensive surgery and reconstructive attempts, recurrences may still occur.
25
Some prognostic factors following surgery were explored in one study of 35 cats. Tumor location did not
seem to affect whether a tumor recurred. However, cats that had a surgery with histologically complete margins had
224
a median tumor-free survival of more than 16 months. Surgeries that had “dirty” margins led to tumor recurrence a
median of 4 months after surgery, which is consistent with other studies cited above, and a median survival of only 9
months. In addition, cats that had not been treated with surgery prior to the definitive resection (i.e., this was their first
surgery) had a median disease free interval of longer than 16 months. In comparison, cats that had undergone one
or more attempts at excision prior to definitive surgery had a median disease free interval of only 5 months and a
25
median survival of 13 months.
Another study showed that the median survival time of cats that had surgery for soft tissue sarcoma was 608
2
days (range, 85 to 2,291 days), although 24 cats were still alive at the time of the study. Tumor size (ie, diameter)
and histologic type were significantly associated with survival time. Median survival time was significantly longer in
cats with tumors that were < 2 cm in diameter, compared with cats in which tumors were > 2 cm.
Median survival times for cats with a fibrosarcoma or nerve sheath tumor were significantly longer than median time
for cats with a malignant fibrous histiocytoma.
3
Another study pushed the frontiers of surgical margins. In that study, the overall median survival time in
another group of 91 cats that had radical surgery (>5 cm margins) for soft tissue sarcomas was 901 days.
Median survival time of cats with and without recurrence was 499 and 1,461 days, respectively. Median survival time
of cats with and without metastasis was 388 and 1,528 days, respectively.
Radiation Therapy
Most early studies report very little efficacy for radiation therapy in reducing recurrence rates for soft tissue
sarcoma. A combination of minimal surgical excision and low doses of radiation therapy probably contributed to the
35–37
apparent ineffectiveness. More recent studies suggest that the treatment of choice for this tumor type is
aggressive surgery in combination with high doses of pre- or postoperative radiation therapy.
192
In two studies, cats were treated with brachytherapy using iridium-192 ( Ir) implants after surgery. The dose
24 31
in one study was 60 Gy but was not provided in the other. The recurrence rate in one study was 70% (11 of 16
24
cats), with a median survival of 8 months ; in the other group of cats, 50% of tumors recurred and the median
31
disease free interval was 12.5 months, which was better than for cats in the same study treated with surgery alone
(discussed previously).
192
Selection of cats with poor prognostic factors may have influenced outcome in another study in which I
25
brachytherapy or cobalt-60 teletherapy resulted in a median disease free interval of only 4.5 months. Information
about radiation doses was not provided.
In a study of 31 cats treated with orthovoltage radiation to a dose of 51 to 60 Gy following incomplete
38
surgical excision, median tumor free interval was 18 months and median survival was 22 months. Acute toxicities
were mild, but systemic toxicities led to the euthanasia of 6 cats, 2 due to pneumonitis and 4 due to renal failure.
These toxicities occurred because of radiation of underlying structures when injection site sarcomas of the
interscapular area or the flank were treated.
High-dose radiation therapy (57 Gy) was used to treat 25 cats with soft tissue sarcomas. An electron beam
was used to deliver the radiation to most cats; this method delivers radiation to superficial tissues while sparing the
39
underlying normal tissue, thereby avoiding toxicity. Median survival for all cats was 700 days. In this small group of
Track A
cats, the administration of doxorubicin chemotherapy was not associated with longer survival, but further studies are
warranted as other anecdotal experience indicates that chemotherapy may improve survival. Increasing numbers of
surgeries prior to radiation was not associated with decreased survival.
Sarcoma recurrence after radiation may be due to improved tumor cell survival along the relatively hypoxic
surgical scar. Hypoxia reduces the effectiveness of radiation therapy. One study investigated the efficacy of
26
presurgical radiation therapy to an area surrounding the tumor followed by wide surgical excision. The tumor
recurred in 11 of 33 cats, and 8 of 33 developed metastases (4 also experienced tumor recurrence). The tumor was
more likely to recur quickly in cats in which surgical excision was incomplete after radiation therapy. Tumors recurred
in the 5 cats with incomplete resection a median of 3.5 months after surgery, while those with complete resection
26
were tumor free a median of 23 months after surgery. Tumor volume at the time of radiation did not influence
recurrence or survival, implying that even large tumors could be treated in this manner. Some cats developed
transient pneumonitis, and wound dehiscence occurred and was repaired in 4 of 33 cats. It appears that radiation
may act to “sterilize” the margins of a tumor, enabling a more effective surgical excision. Radiation therapy followed
by aggressive surgery may be the treatment of choice for feline soft tissue sarcomas.
7
A retrospective study was more recently performed in 73 cats with vaccine-associated sarcoma given
postsurgical curative (most with clean margins) or coarse fractionated radiotherapy (most with either macroscopic
disease or dirty margins). The former animals displayed a median survival of 43 months and a median progression
free interval of 37 months, the latter reached a median survival of 24 months and a median progression free interval
of 10 months.
Chemotherapy
There is very little information regarding chemotherapy in the treatment of soft tissue sarcomas in cats. The
reportedly low metastatic rate has meant that chemotherapy is rarely used in an adjuvant setting. The higher
225
metastatic rates now reported and the reduction in the rate of local recurrences following the use of surgery and
radiation therapy indicate that chemotherapy may have an increasing role in the management of soft tissue
sarcomas in cats.
Drugs that anecdotally appear to have no efficacy are vincristine, methotrexate, and
19,27,35
cyclophosphamide. Doxorubicin has been used with apparent success to treat cats with local recurrence after
40 35
surgery, although other studies indicated no response to treatment. Mitoxantrone did not influence tumor
33
recurrence in a cat with soft tissue sarcoma. The use of carboplatin chemotherapy did not seem to improve survival
25
rates in another study, although some oncologists believe that this drug is helpful. Similarly, studies are currently in
a
progress to investigate the efficacy of ifosfamide, a drug that is very effective against soft-tissue sarcomas in
humans.
In an investigation of a novel approach to treat recurrent sarcomas, IV bleomycin (0.5 mg/kg) was combined
41
with electric stimulation of sarcoma and immunotherapy. Tumor regression was seen in only one cat, but survival
appeared to be prolonged (5 months) compared with untreated cats (0.7 months).
In another study, either doxorubicin, mitoxantrone, or carboplatin was administered to seven cats in which
26
sarcoma recurred after surgery and radiation. The median survival for these cats was 3.5 months, and two cats
were alive 10 to 22 months after treatment. Doxorubicin and carboplatin need to be further evaluated in the treatment
of soft tissue sarcomas in cats, particularly as an adjuvant to surgery and radiation therapy. Having stated that one
5
study involving 91 cats that underwent postoperative definitive radiotherapy for treatment of incompletely
excised soft tissue sarcomas with or without concurrent doxorubicin chemotherapy were evaluated. Median disease-
free interval with concurrent radiotherapy and doxorubicin chemotherapy (15.4 months; range, 2.4 to 44.9 months)
was significantly longer than median disease-free interval with radiotherapy alone (5.7 months; range, 1.0 to 50.8
months).
4
More recently, a study was completed involving 21 cats with soft tissue sarcomas that received 3 cycles of
neoadjuvant chemotherapy with epirubicin followed by surgery to resect of the entire muscle compartment containing
the tumor followed by 3 cycles of adjuvant chemotherapy. A median survival time could not be calculated as over
80% of the study population remained alive or were censored due to death from other causes. When compared to
historical controls, the results of this study demonstrate superior rates of tumor-free survival and disease-free
interval.
Immunotherapy
Nonspecific immunomodulation using a mixed bacterial vaccine or levamisole had no obvious effect on
19,27
recurrence rates or survival following surgical excision of soft tissue sarcomas.
Acemannan is another nonspecific immunomodulator that has been evaluated in a small number of cats with
fibrosarcoma. Cats were injected with 2 mg/kg intralesionally weekly for 6 weeks prior to surgery and megavoltage
radiation therapy (60 Gy). The cats then received 1 mg/kg intraperitoneally weekly for 6 weeks and then monthly for
1 year. Of four cats so treated, one had tumor recurrence 8 months after surgery but the other three had no
42
recurrence for 14 to 19 months after surgery. The true contribution of acemannan to survival in these cats is difficult
to evaluate.
Track A
Tenogeneic cells (Vero hIL-2) that secrete human recombinant interleukin-2 (hrlL-2) were infiltrated around
192 24
the tumor at the time of surgical resection and implantation of Ir seeds for brachyradiotherapy. This infiltration
was repeated 5 days later and another five times over the next 2 months. Of 16 cats treated by this protocol, two had
local recurrence and three had metastases, with an overall median survival of 16 months. In comparison, 11 of 16
cats that did not receive Vero hlL-2 cells had tumor recurrence and a median survival of 8 months. Antibodies to the
cells were detected after 5 days of treatment, and most cats had a local inflammatory reaction to injection. One cat
24
developed anaphylaxis.
Immunotherapy may contribute to longer survival in cats treated with local therapies for fibrosarcoma.
Further studies involving the use of specific immunomodulators are needed to define the role of immunotherapy. The
Merial Oncept IL-2 vaccine was recently approved for use in cats with fibrosarcomas that are 2–5 cm in length as
part of a treatment protocol combining surgery and adjuvant radiotherapy. This vaccine is a feline interleukin (IL)-2
recombinant canarypox virus vaccine that is injected directly into the tumor bed. The idea is that the vaccine will
produce IL-2 locally without causing the side effects seen if it were given systemically.
Injection Site (Vaccine Associated) Sarcomas

Soft tissue sarcomas that occur in the subcutis of the dorsal neck/interscapular area, flank/paralumbar area,
43
dorsolateral thorax, and femoral musculature have been increasing in frequency. These sarcomas have been
termed injection site sarcomas or vaccine associated sarcomas due to their anatomic location at common sites of SC
injection. One study showed an eightfold increase in the number of sarcomas diagnosed from 1988 to 1994 and a
44
similar increase in the ratio of injection site to noninjection site sarcomas. In the 5 years from 1984 to 1988,
injection site sarcomas outnumbered sarcomas at other sites only once, while between 1989 and 1992 they were the
226
44
most common type. This coincides with widespread rabies vaccination and availability of FeLV vaccines. In three
43–45
large studies encompassing 773 cats with sarcomas, 489 tumors occurred at injection sites.
Injections site sarcomas occur in younger cats than do sarcomas at noninjection sites, with a peak at 6 to 7
43,44,46
years of age. The signalment of affected cats is otherwise similar whether the sarcoma is injection site related
43
or not.
These tumors are most commonly fibrosarcomas but may also be described as osteosarcoma, malignant
fibrous histiocytoma (histiocytic sarcoma), giant cell tumor, myofibroblastic sarcoma, rhabdomyosarcoma,
leiomyosarcoma, chondrosarcoma, undifferentiated sarcoma, neurofibrosarcoma/nerve sheath tumor, and
liposarcoma. The majority of injection site sarcomas have been associated with vaccination, particularly rabies and
44,45,47
FeLV vaccines. Sarcomas have also been associated with feline panleukopenia, herpesvirus, and calicivirus
48,49
vaccination in countries where vaccination for rabies and FeLV are not common. Sarcomas appear to arise
44,47
months to years after vaccination. Injection site sarcomas have also arisen at the site of antibiotic administration,
44,49–51 48
SC fluid administration, long-acting corticosteroid injection, or lufenuron injection (Program 6 month
52
injectable).
There have been many estimates of the incidence of sarcomas that occur following vaccination. Most have
been based on estimates of the number of cats truly vaccinated, and all rely on what could be incomplete or biased
reporting of tumors.
In California, one study estimated that between 10 and 12 cats/100,000 would develop a sarcoma at a
44
vaccination site. A nationwide study involving 235 practitioners affiliated with the American Association of Feline
53
Practitioners looked at the 1992 incidence of sarcomas in vaccinated cats. This study found that 48% (158 of 329)
were at vaccination sites and the incidence was 36 cats/100,000. Other estimates have ranged from 10/100,000 to
54 48
100/100,000. One small study showed the risk of sarcoma formation to be 130/100,000 vaccinations.
Injection sites sarcomas are often associated with an inflammatory infiltrate, primarily macrophages, that are
46,47 46
frequently reported to contain bluish “foreign material” and may include giant cells. In one study, aluminum was
associated with this inflammation, leading to speculation that aluminum containing adjuvants in vaccines may cause
55
inflammatory changes that lead to carcinogenesis. Trials with adjuvanted killed vaccines in 36 cats showed that
80% to 100% of cats had a local inflammatory reaction following vaccination and that rabies vaccination created a
50,54
larger inflammatory mass than did vaccination for FeLV. Although reactions were most common with aluminum
adjuvant vaccines, less common with non-aluminum adjuvant vaccines, and not seen with nonadjuvant vaccines, the
size of the reaction was not related to the presence of aluminum. IM injection has been shown to cause the same
50 48,56
reaction as SC injection, and sarcomas have occurred at IM injection sites, although they appear to be less
44
common at this location.
48
One study showed an increasing risk of sarcoma formation with the use of killed vaccines. The risk of
sarcoma formation appears to be greatest following FeLV vaccination, with vaccinated cats being nearly three times
44
more likely to develop a tumor than cats not receiving FeLV vaccine. Rabies vaccination is less strongly associated
44
with sarcoma formation, with vaccinated cats about twice as likely to develop a tumor. Since adjuvants are used
with killed vaccines and appear responsible for much of the inflammation, some investigators have suggested the
preferential use of modified-live vaccination. However, some sarcomas have been associated with modified-live virus
Track A
49
vaccination.
The risk of sarcoma development increases with the number of vaccines given at a site. In one study, cats
receiving three to four vaccinations in the interscapular region were nearly twice as likely to develop a sarcoma than
44
if they received one vaccine at that site.
In one study of cats with sarcomas, vaccines received were cataloged according to their manufacturer. There
were seven manufacturers of FVRCP vaccines, five manufacturers of FeLV vaccines, and eight manufacturers of
44 45
rabies vaccines. There was no association between manufacturers and vaccine formation in this or other studies.
It has been known that inflammation may cause sarcoma development in cats because ocular sarcomas at
57,58
the site of ocular trauma have been described. Fibrosarcomas have also been induced by trauma in cats infected
59
with FeSV. FeSV requires FeLV as a “helper” virus in order to proliferate, so if FeSV were to be implicated in
injection sarcoma carcinogenesis, affected cats would be FeLV positive. Of 169 cats with sarcomas in one study,
44
only 8 were FeLV positive and only 4 of these had injection site sarcomas. In addition, of 36 cats tested for FIV,
only 3 were antibody positive and only 1 of these had an injection site sarcoma. In a second study, all tested cats
45
were FeLV and FIV negative. Immunohistochemical staining of 130 injection site sarcomas showed no evidence of
60
FeLV gp70, and polymerase chain reaction showed no evidence of FeLV in 100 injection site sarcomas. It seems
unlikely that FeSV is involved in injection sarcoma development.
The development of sarcomas does seem to be related to the presence of oncogenes and mutations in
61
tumor suppressor genes. Approximately 75% of injection sarcomas were found to contain p53 and c-kit oncogene.
Approximately one third of tumors contained both p53 and mdm-2, and these tumors were histologically more
anaplastic, perhaps explaining the aggressive biologic behavior of some injection site sarcomas.
The current thinking is that individual cats may respond to inflammatory changes in a manner that
predisposes to sarcoma formation. This is supported by the discovery of cats that have developed sarcomas at more
50
than one injection site and the finding of injection site sarcomas in related cats. Current studies to investigate the
227
cytogenetics of injection site sarcomas may provide more information. Up-to-date information regarding research can
be obtained from the Vaccine Associated Fibrosarcoma Task Force (http://www.avma.org/vafstf/default.asp).

The occurrence of a mass at a site commonly used for SC or IM injections should alert the clinician to the
possibility of an injection site sarcoma. In particular, biopsy samples should be collected from a vaccination reaction
that persists or starts to increase in size. In one study, most reactions following rabies or FeLV vaccination had
5
resolved within 2 to 3 months ; some oncologists believe that a biopsy sample should be obtained when a vaccine
reaction persists longer than 1 month.
Injection site sarcomas are more likely to appear in the subcutis, while noninjection site tumors occur more
43
frequently in the dermis. Injection site sarcomas are usually larger than those at other sites. In one study, 26 of 54
45
(48%) injection site tumors had a diameter of 4 cm or more and only one tumor was less than 1 cm in diameter. In
contrast, 16 of 63 (25%) sarcomas at other sites were at least 4 cm in diameter and 10 were less than 1 cm. It is
possible that this reflects the inability of an owner to detect tumors at injection sites and emphasizes the need for
owner education to improve early detection of tumors.

Fine needle aspiration of an injection site sarcoma may reveal a spindle cell sarcoma or mesenchymal
tumor. The exact histologic diagnosis matters less than the classification as a soft tissue sarcoma. Most oncologists
recommend an initial needle or incisional biopsy rather than an attempt at excisional biopsy. This is because an
aggressive first surgery or presurgical radiation therapy will provide a better outcome than will treating a recurrence.
Injection site sarcomas often contain necrotic areas, probably secondary to vascular thrombosis and
43
abscessation. These tumors are more likely than noninjection site tumors to show lymphocytic and macrophage
43,46
inflammation, often progressing to granulation tissue. These inflammatory macrophages often contain
47
phagocytosed bluish material, which may be vaccine adjuvant.
Histologically, injection site sarcomas are locally invasive, have more mitotic figures, and appear more
43,47
pleomorphic (less differentiated, more anaplastic) than noninjection site tumors. Indeed, only injection site
43
sarcomas showed production of osteoid, chondroid, or myxomatous tissue in one study. The intercellular matrix
was more variable in these tumors. Malignant fibrous histiocytoma (histiocytic sarcoma) was a diagnosis made only
43,45
at injection sites in two studies and appears to be associated with vascular invasion more commonly than other
43
types of sarcomas.
There may be increased risk of metastasis from injection site sarcomas. In one study, staging procedures
45
prior to initial treatment revealed no evidence of metastasis in any cat. However, following diagnosis and treatment,
three cats developed pulmonary metastases and a fourth developed skeletal metastases from injection site
sarcomas; only one cat developed pulmonary metastases from a noninjection site sarcoma.
Seven individual case reports have documented metastases from injection site sarcomas. Five cats had
48,62–65
interscapular tumors, three of which metastasized within 4 months of the first surgical excision. The other two
54,55
cats had a tumor of the flank or hip. The most common metastatic site was the lungs (five cats), followed by the
Track A
liver (three ), mediastinum (two), spleen (two), kidney (two) and eye, pancreas, and intestines (one each).
64,67
Interestingly, abdominal metatases were all that were detected in two cats.
In addition to needle biopsy of the tumor, staging for cats with suspected injection site sarcoma should
include an MDB, thorough history of previous vaccinations and injections, and abdominal ultrasound. A CT scan or
MRI should also be performed to allow delineation of the margins of the tumor for appropriate surgical planning.
Regional lymph nodes should be palpated and aspirated if enlarged.
Treatment
Treatment options are the same as outlined for other soft tissue sarcomas. There is some concern that
67
delaying surgery may increase the likelihood of metastasis.
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Track A
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230
NOTES:
Track A
231
NOTES:
Track A
232
10 Best Kept Secrets for Treating Cats with Cancer

Introduction
Feline medicine and, in particular, feline oncology is associated with a great deal of myth and mystery. Cats
are unique in physiology, behavior, anatomy, social structure, and in the types of diseases they have and the
pathogenesis of these diseases. Cancer is rarely discussed in great detail in textbooks and often the data that is
used to reference the information is outdated or incorrect. The purpose of this document is to review some of the
unique aspects associated with feline medicine and to outline the unique biological behavior of several different
malignancies and the cats’ response to those malignancies. By understanding this information, a clinician can have a
much higher probability for enhancing and improving quality of life.
The document below is in an unusual format that darts between statements of “secrets” yet followed at points
by text to give deeper understanding. Some you already know, others may surprise you. Still others will be replaced
between the time of the writing of this text and the presentation. Get your pencils sharpened!
The Secrets Begin

Secret #1: Cats generally resist restraint; and therefore, the less restraint is generally the best restraint. When cats
close their eyes (or we close them), they instantly become invisible.
Secret #2: 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.
Secret #3: 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 that are
treated with chemotherapy and radiation therapy, cats generally do far better than dogs.
Secret #4: 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.
Secret #5: 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.
Secret #6: 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.
Secret #7: 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. Interestingly, the feline 'lung-digit syndrome' is
Track A
an unusual pattern of metastasis that is seen with various types of primary lung tumors, particularly bronchial and
bronchioalveolar adenocarcinoma that present for metastases to the distal phalanges of the limbs.
Secret #8: Size of the feline mammary tumors is prognostic.
Secret #9: A dyspneic cat is a cat with severe intrathoracic or upper airway pathology.
Secret #10: 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. Obviously, with CT scans becoming more available in veterinary medicine, this is often used to provide
greater understanding of intrathoracic disease. This is accentuated by performing bronchoscopy and bronchoalveolar
lavage.
Secret #11: 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.”
Secret #12: 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.
Secret #13: 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.
233
Secret #14: Robenacoxib, Piroxicam, Metacam, 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
currently not 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. The International Society of Feline Medicine (ISFM) and the American Association of
Feline Practitioners (AAFP) published a set of guidelines for the long-term use of NSAIDs in cats. These guidelines
promote the effective and safe use of NSAIDs in this species. The guidelines cover common causes of chronic pain
in cats, why NSAIDs can have many positive and potentially negative actions, patient selection, techniques for
promoting owner and cat compliance, dosing recommendations, and concurrent conditions which may make a
patient a "higher risk" candidate for NSAID therapy. The document also discusses pre-treatment screening and
monitoring for adverse effects during therapy. The guidelines can be downloaded at the ISFM (www.isfm.net) and
AAFP (www.catvets.com) websites. Many of the concerns about the use of NSAIDs relate to the cat's unique
metabolism; the relative deficiency of glucuronyl transferase enzymes in this species may lead to a prolonged half-
life for some drugs; however, some NSAIDs including meloxicam, piroxicam and robenacoxib are cleared by
1,4
oxidative enzymes and do not appear to have prolonged half-lives in cats and are less likely to accumulate.
NSAID Half-life (hours)
Carprofen 20
Ketoprofen 1.5
Meloxicam 15
Piroxicam 12
Robenacoxib 1.1–1.7
Secret #15: Tramadol is very effective for treating pain in the cat 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.
Secret #16: Buprenorphine and fentanyl are two of the most commonly used opiates in the cat other than
Track A
butorphanol. When morphine and fentanyl are compared, fentanyl has at least a theoretical benefit over morphine,
because morphine is far more lipid soluble, and therefore more rapid-acting. There is a new injectable sustained
release fentanyl and buprenorphine product. The SC route of administration does not appear to provide adequate
antinociception and analgesia whereas the buccal route has produced inconsistent results. Intravenous or IM
administration at a dosage of 0.02-0.04 mg/kg is the preferred for treatment of pain in the acute setting.
Secret #17: Fentanyl patches are very 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.
Secret #18: 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.
Secret #19: 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.
Visceral Mast Cell Tumors

The principle site for visceral mast cell tumor (MCT) is the spleen. In a survey of 41 cats with this disease, 35
2
had splenic MCT, 4 had mediastinal MCT, and 2 had MCT that primarily affected the peripheral lymph nodes. While
it is possible for cutaneous MCT to spread systemically, this is considerably less likely to occur in cats than in dogs
and the viscera usually appear to be the primary site. Unlike cutaneous MCT, visceral MCT occurs most commonly in
234
4 5
DSH and DLH cats and is rarely reported in Siamese, Maine Coon cats, or other purebreds. This disease has been
6 2,5,7
reported in cats as young as 3 years of age but usually occurs in older cats (average age, 8 to 10 years).

Cats with visceral mast cell disease may present for nonspecific malaise, inappetence, weight loss, or
5,8,9 5
vomiting. Vomiting may be occasional but may also have persisted for up to 6 weeks prior to presentation. In one
5
study, chronic vomiting was a sign in seven of seven cats and was presumably due to gastroduodenal ulceration
following the release of vasoactive amines (e.g., histamine, serotonin) that cause gastric parietal cell hyperplasia and
increased gastric acid production. These ulcerations can be extensive and may eventually perforate, causing sudden
10,11 12 2
death due to hemorrhage or peritonitis. Splenic rupture may also occur. Sudden increase in the frequency of
vomiting in a cat that has been vomiting intermittently, particularly when accompanied by anorexia, may be a sign
8
that ulceration has worsened.
13
Abdominal distention may be noticed by the owner and may be a chronic condition in some cats.
2,14
Abdominal distension may be due to ascites (present in up to one third of all affected cats ) or possibly a massively
enlarged spleen. A spleen that is infiltrated by neoplastic mast cells may be 28 cm long, 8 cm wide, and up to 2 cm in
4,5,11
thickness and may have a white fibrinous capsule. Abdominal discomfort may also occur as a consequence of
15
organomegaly.
Involvement of the liver and less commonly the lungs, kidneys, and bone marrow may be noted when the
7
spleen is very enlarged. Rarely, a cat with multiple cutaneous metastases noticed by the owner will be found by the
6,12
veterinarian to have a primary visceral MCT.
Cats with mediastinal MCT will present with dyspnea due to either pleural effusion or a large mass that
causes an incompressible anterior thorax.

While the spleen is the most common primary site for visceral MCT, the liver is involved in up to 90% of
2
affected cats. Other common sites of involvement (listed in decreasing order) are the visceral lymph nodes, bone
2,7
marrow, lung, intestine, and kidney. Thus complete staging should include an MDB, abdominal radiographs or
ultrasonography, and bone marrow aspiration. Aspiration cytology or a preoperative biopsy of the spleen may also be
helpful.
Abdominal radiographs may demonstrate enlargement of the spleen and liver or even a mass effect,
13
although the picture is often obscured by the presence of ascites. Ultrasonography allows detailed visualization of
abdominal organs and is unaffected by the presence of ascites. It is the imaging method of choice for these cats and
13,15
may confirm a mass lesion or infiltrative pattern. . Thoracic radiographs may demonstrate pleural effusion or an
anterior mediastinal mass; however, pulmonary infiltrates may be mild and difficult to distinguish from nonneoplastic
processes.
Ascitic fluid may be reactive and not contain mast cells, and thus cytologic examination may not be
13
diagnostic. Fine-needle aspiration cytology from the spleen can often provide a diagnosis with minimal patient
6,8,13
trauma . To reduce the risk of bleeding or degranulation, a 25-ga needle may be used to obtain a sample.
Track A
A complete blood count will provide valuable information. Up to one third of cats with visceral MCT are
2,5
anemic. Anemia may be due to chronic blood loss from GI ulceration or to suppression of erythrocyte production by
the bone marrow following infiltration by neoplastic cells. Erythrophagocytosis by malignant splenic mast cells was
16
described in four cats with visceral MCT. Circulating mast cells may be seen on the routine blood smears and often
4,6,9,17,18
account for 5% to 25% of circulating white blood cells. Interestingly, the numbers of circulating mast cells
2
have been reported to fluctuate in individual cats. Basophilia may accompany mastocythemia. If systemic mast cell
disease is suspected, a buffy-coat preparation from a microhematocrit tube may improve chances of tumor cell
detection
A bone marrow aspirate should be performed as part of the staging procedure. Bone marrow involvement
2,7–9
occurs in 20% to 40% of cats with visceral MCT.
If there is concern regarding gastric or duodenal ulceration, endoscopy may provide a definitive diagnosis but
will not be therapeutic. Conversely, if ulcerations are noted in a chronically vomiting cat, the other staging procedures
outlined above may help to diagnose an underlying MCT.
Treatment
Palliative medical treatment of visceral MCTs does not seem to result in significant clinical improvement.
Corticosteroids and antihistamines (specifically the H1-blocker diphenhydramine) do not seem to reduce the
8
incidence of vomiting or result in tumor regression, although one cat remained stable for 20 months before it died of
18
concurrent lymphoma.
Splenectomy is the treatment of choice, even in cats with other evidence of systemic involvement. Cats with
6,17
circulating mastocythemia may have complete normalization of their hemogram 4 to 5 weeks after surgery. Of 21
reported cats undergoing splenectomy, survival ranged from 2 months to 34 months (median, approximately 12
2,4–6,13,15,17
months). There was still gross evidence of disease in some cats that survived a long time. One cat
235
developed cutaneous and mucosal MCTs 6 months after surgery. The tumors continued to increase in number, but
4
there were no signs of systemic illness 30 months after surgery. Owner tolerance obviously plays a role in survival,
6
because another cat was euthanized 2.5 months after surgery because its cutaneous lesions did not regress.
Recurrence of GI signs (vomiting, diarrhea) that had ceased after splenectomy was the reason for
5,17
euthanasia in most other cats, and this occurred 6 to 25 months after surgery.
Concern over the release of vasoactive amines due to surgical manipulation during splenectomy has led to
the recommendation that cats be treated with corticosteroids and both H1 and H2 blocking antihistamines for 48
hours prior to surgery. It appears that serotonin may be a more important vasoactive substance in cat mast cells, so
19
it is possible that cyproheptadine may prove a better drug for symptomatic relief and preoperative GI protection.
The role of corticosteroids and antihistamines after splenectomy is uncertain. Because some investigators
believe that regression of disease following splenectomy may be immune mediated, the use of corticosteroids is
often discouraged because of their potential immunosuppressive effects. In contrast, a cat that collapsed with bloody
ascites after splenectomy was maintained for an additional 2 years on prednisone despite persistence of the
13 5
ascites. Antihistamines led to resolution of vomiting in another cat, and the author of that report recommended the
use of cimetidine postoperatively. The efficacy of H2 receptor antagonists remains unknown.
The usefulness of chemotherapy has not been reported for visceral MCTs in cats. In dogs, CCNU,
vinblastine, L-asparaginase, and chlorambucil have at least anecdotal activity against cutaneous MCTs and thus may
be worth considering in cats with MCTs.
Supportive care is essential, particularly postoperative analgesia and nutritional support. Antiemetics can be helpful
in decreasing nausea and vomiting if chemotherapy is used but are unlikely to affect tumor-induced vomiting.
The Secrets Continue

Secret #20: Radiation therapy with a radiation sensitizer, such as gemcitabine, has been touted as being effective;
but ultimately, when comparing oral facial squamous cell carcinomas, bone involvement is generally a better
prognosis.
Secret #21: Unlike in the dog, surgery alone is often associated with long-term control and/or cure.
Secret #22: 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.
Secret #23: 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.
Secret #24: Ptyalism is the most common clinical sign in cats with portosystemic shunts.
Secret #25: Clinical icterus should be present if the bilirubin value is greater than 2mg/dl. If clinical icterus is not
present, then one should consider that the bilirubin elevation is likely due to a lab error, lipemia, or hemolysis.
Secret #26: Serum alkaline phosphatase in the cat has a half-life of six hours and there is no steroid isoenzyme in
the cat.
Secret #27: If the serum alkaline phosphatase is much greater than the ALT, and the ALT somewhat greater than
the GGT or the GGT is normal, then hepatic lipidosis is often the cause. If the ALT is substantially elevated and the
serum alkaline phosphatase is greater than the GGT, then hepatitis or chronic hepatocellular disease is likely the
Track A
cause.
Secret #28: The AST is not liver specific in the cat.
Secret #29: Any bilirubin in the urine is abnormal in the cat.
Secret #30: If the bilirubin is greater than 3mg/dl, 90% of the cats will have a hepatic problem. If the serum bilirubin
is less than 3mg/dl, 50% of cats will have a non-hepatic problem.
Secret #31: Feline needle aspiration is often very helpful for diagnosing hepatic lipidosis. Wedge biopsies are
however superior to needle aspirations and needle core biopsies.
Feline Liver Enzymes

Serum Alanine Aminotransferase (SALT)
SALT is the most liver-specific enzyme in the cat. This enzyme is used to detect hepatocyte membrane
damage and necrosis. This enzyme is found only in the cytoplasm. Serum activity increases when there is increased
permeability and thus leakage of the hepatocyte membrane. The extent to which enzyme leakage occurs depends on
both the severity and the number of cells damage but does not indicate the reversibility of the injury or the functional
status of the liver. The activity of SALT is highest in cases of chronic active hepatitis, primary hepatic neoplasia, and
hepatic necrosis. There is often normal or only mildly increased SALT activity in cases of portosystemic shunts,
cirrhosis, and metastatic neoplasia.
Serum Alkaline Phosphatase (ALP)
The activity of ALP is much lower in cat than the dog because the half-life of ALP is much shorter in the cat
(6 hours vs 3 days) Less feline ALP is produced secondary to biliary obstruction than in the dog because the feline
liver contains only one third the concentration of ALP per gram of liver than that of the canine liver. Thus, mild
elevations of ALP activity in the cat are indicative of marked hepatobiliary disease. The magnitude of increase in ALP
236
activity is most marked with feline hepatic lipidosis, almost always exceeding the magnitude of increase in serum
GGT activity in feline hepatic lipidosis.
Gamma Glutamyl Transpeptidase (GGT)
GGT activity has a higher sensitivity but lower specificity than does serum ALP for detection of liver disease.
In feline hepatic lipidosis the magnitude of increase in serum ALP activity exceed that of serum GGT activity. Serum
GGT activity has a higher positive predictive value, whereas ALP activity has a higher negative predictive value for
evaluating hepatobiliary disease. The diagnostic performance is best when both enzyme activities are evaluated
together. In general, GGT activity is less influenced by nonhepatic diseases or enzyme-inducing drugs.
Hepatocellular Carcinoma
Tumors of the liver parenchyma are less common in cats than tumors of the biliary tree. This means that the
signalment and outcome for cats with hepatocellular carcinoma is often obscured in large studies due to lack of
discrimination between cases.
The median age of 11 cats for which information was available 11 years (range, 2 to 18 years). Using
2
reported information, there were 11 males; 16 cats were DSH and 2 were Siamese.
Toxicity trials using diethylnitrosamine in cats induced multiple types of liver tumors, including hepatocellular
48
carcinoma, 1 to 2 years after exposure.

Signs are mostly nonspecific, such as anorexia and weight loss, but ascites, polydipsia, and palpable
2,27
abdominal masses have been reported. In another study, signs of vomiting, diarrhea, weight loss, and an
49
abdominal mass were absent in two cats with hepatocellular carcinoma ; hemorrhage from a ruptured tumor caused
2
sudden death in one cat. The tumor may appear as a solitary large mass or as multiple nodules.

The histopathologic appearance of hepatocellular carcinoma does not appear to correlate with metastatic
2 2,25
behavior. Metastases were seen in 7 of 26 cats with hepatocellular carcinoma. The hepatic lymph nodes were the
most common metastatic site (4 cats), but the spleen (2 cats) and lungs (2 cats) were also affected.
Unrelated tumors of the liver were common in one group of 18 cats with hepatocellular carcinoma; three cats
2
had biliary cystadenomas, 1 had a myelolipoma, and 1 had an MCT. Another cat with hepatocellular carcinoma had
49
a biliary cystadenoma. Staging for a cat with hepatocellular carcinoma should therefore include abdominal
ultrasonography (and/or CT or MRI) in addition to an MDB. Biopsy specimens should be collected from enlarged
hepatic lymph nodes at the time of surgery.
Treatment
Surgery should be the treatment of choice for solitary hepatocellular carcinomas, although survival data is
Track A
not available for cats treated in this way. Supportive care is important, and postoperative analgesia and nutritional
support should be considered.
Hepatoma or Hepatocellular Adenoma

This is an uncommon tumor and difficult to distinguish histologically from low grade hepatocellular
2,25
carcinoma. Hepatomas were not reported in two studies that included 57 cats with liver tumors. In another study, 9
cats with hepatoma were included with cats that had other benign liver tumors. This group of cats tended to be older
27
than those with malignant tumors, and there was no gender predilection. Multiple hepatomas are occasionally
50
reported .

One cat with hepatoma had marked weight loss over several months as well as muscle weakness and
51
fasciculations due to severe hypoglycemia. This cat had a very large palpable liver mass (5.5 cm in diameter).
52
Another cat died suddenly due to rupture of a hepatoma 8 months after it was initially diagnosed.
Hepatocellular adenomas can also be quite small. In one series, only one of nine cats had a palpable
abdominal mass; hepatomas were incidental findings at necropsy in the other eight cats

Staging is as for other liver tumors. Hypoglycemia in the face of decreased serum insulin was seen in a cat
51
with a large hepatoma. Liver enzymes were increased, although serum bilirubin was normal.
237
Treatment
The large hepatoma in the aforementioned cat was believed to be unresectable, so the cat was maintained
on multiple small meals daily for 6 months. No other treatment for these tumors has been reported.
Bililary Adenomas
Other nomenclature for these tumors includes bile duct adenoma, biliary cystadenoma, biliary adenoma, and
cholangiocellular adenoma.
2,53,54
These tumors occur almost exclusively in older cats (12 to 18 years of age), although two 6-year-old
2,54
cats, including a Persian, have been described. Otherwise, the majority of affected cats have been DSH or DLH,
2,53,54 53,55
. There does not appear to be a gender predilection, although 17 of 23 cats in two studies were males.
25
Adenomas may show anaplastic or dysplastic changes that signal transformation to adenocarcinoma.
Three young cats in Hong Kong developed biliary adenoma after infection with a liver fluke (Chonorchis
56
sinensis). One of the cats was experimentally infected and developed a tumor within 4 months.

49 2
Biliary cystadenomas may be multiple and occasionally can be very large ( up to 9 cm in diameter). An
27,49,53–55,57
abdominal mass was palpable in 29 of 51 cats with this tumor type, although biliary adenomas were still an
53
incidental finding in many cats.
54
Clinical signs such as lethargy, vomiting, and polydipsia may not be specific for biliary adenomas.
54 27
Abdominal swelling due to ascites or a mass may be noticed by owners. While jaundice is rare for benign tumors,
53
it may still be a sign that leads to a diagnosis of biliary adenomas, depending on tumor location.

25
Transformation of biliary adenoma to biliary adenocarcinoma may be a common event, and both tumor
49,56
types may be found in the same cat. Hepatocellular carcinoma was also present in 3 of 18 cats with biliary
49
adenoma.
As for other liver tumors, radiography may disclose a hepatic mass but ultrasonography will allow the
clinician to decide if surgery is an option (solitary large lesion) or not. Ultrasonography is excellent for detecting
tumors larger than 2 to 3 mm, although larger tumors may be missed because their ventral location can be obscured
55
by “near-field” reverberations. Ultrasound-guided needle core biopsy is mandatory for definitive diagnosis.
Unrelated tumors have been reported in some cats. In one study, 8 of 34 cats with biliary adenoma also had
2,25
lymphoma or MCTs . In another study, 2 of 10 cats had pancreatic carcinoma and one had carcinomatosis in
55
association with biliary cystadenoma. This means that the clinician should fully evaluate all organ systems by
performing complete staging, including an MDB, abdominal ultrasonography, and biopsy, prior to treating the
adenoma.
Treatment
Track A
Surgical excision appears to be successful in the majority of cats with biliary adenomas. Removal of focal
2,27,53,54 54,57
lesions in eight cats and multiple lesions in two cats via a lobectomy achieved complete surgical margins
in all but one animal. The tumor in this animal was attached to the gallbladder, and the cat still lived 12 months
54
before tumor recurrence was clinically noted. Survival times for the remaining nine cats ranged from 1 to 42 months
27,53,54,57
(median, 22 months), with recurrence noted in only one cat 25 months after surgery. Adjunctive therapy is not
warranted in cats with resectable tumors, and even cats with multiple tumors have a good prognosis following
resection.
Since these tumors may transform to biliary adenocarcinoma, surgical resection is best done early in the
course of disease. It would not be good practice to simply monitor a cat with a solitary biliary adenoma.
Supportive care, including analgesia and nutritional support, should be considered postoperatively.
Bile Duct Carcinoma

Other terms for this tumor include cholangiocarcinoma, bile duct or biliary adenocarcinoma, and biliary
carcinoma. Some authors distinguish between intrahepatic and extrahepatic tumors. Bile duct carcinomas have been
58 2
reported in cats ranging in age from 11 months to 21 years, although most affected cats are older than 9 years. Of
2,58–62
27 cats for which the breed was reported, there were 18 DSH, 8 Siamese, and 1 Burmese. More females than
males are reported, but there does not appear to be a strong predilection except in one study, in which 15 of 20
2
affected cats were female. Natural and experimental infestation with the fluke Clonorchis sinensis has led to bile
56 48
duct carcinoma induction, as has experimental administration of the carcinogen diethylnitrosamine. Residual
benign and precancerous lesions were found concurrently with bile duct carcinoma in 10 of 15 carcinomas affecting
25
the intrahepatic (9 cats) or extrahepatic (4 cats) biliary tree or gallbladder (2 cats).
238
Abdominal distension noted by the owner or a palpable abdominal mass on physical examination led to a
27,49,58–62
diagnosis of hepatic bile duct carcinoma in 18 of 23 cats. Other less specific signs such as anorexia,
depression, vomiting, and weight loss were also reported, although the tumor was occasionally an incidental finding
27,58
at necropsy.
2,59
Icterus appears to be more common with tumors involving the extrahepatic bile ducts than with those
involving the intrahepatic biliary tree. One cat was presented for severe symmetric generalized alopecia;
histologically, the skin had follicular atrophy with minimal inflammation and was identical to a paraneoplastic alopecia
62
seen in some cats with pancreatic carcinoma.

Staging for this disease focuses on evaluating for abdominal disease and metastasis using an MDB and
abdominal ultrasonography. Radiographs may disclose an anterior abdominal mass that is associated with the liver,
27,63
but ultrasonography is the imaging modality of choice. Ultrasonographically, the liver is often diffusely mottled or
has multiple small masses throughout the parenchyma.
59 2,58,60
Ascites is rare and may be due to peritonitis. Evaluations in serum liver enzyme activity may be seen,
59
but this is not a consistent finding. Increases in bilirubin are similarly inconsistent, although all cats that were icteric
27
in one study had a malignant tumor.
Metastasis is common and does not seem to alter with the tumor’s site of origin. In two studies that
distinguished between intrahepatic, extrahepatic, and gallbladder carcinomas, metastasis was detected in 17 of 23
2,25
cats with intrahepatic tumors, 5 of 8 cats with extrahepatic tumors, and 4 of 4 cats with gallbladder tumors. A
64
primary gall bladder tumor metastasized widely in one other cat, causing pleural effusion and dyspnea. The pattern
of metastasis did not seem to differ among the three sites of origin; the most common sites of metastasis were the
2,25
peritoneum, lungs, and regional lymph nodes, while metastases to the diaphragm, spleen, kidney, eye, pancreas,
2,25,58,65
and stomach wall were less commonly reported.
Treatment
Therapy for these aggressive tumors is rarely reported. One cat with ascites that was palliated with
59
prednisone was euthanized 10 days later due to progressive disease.
27
Surgery was attempted in four cats with biliary carcinoma. Three died immediately postoperatively, and the
surviving cat was euthanized due to tumor recurrence 2 weeks after surgery.
Conclusion
Feline medicine and feline oncology specifically is a unique art form that requires a revised understanding of
the pathogenesis of disease and the physiology of the cat. Approaching the cat as a unique species and not as a
small dog can enhance the ability to diagnose underlying disease as well as to provide a treatment plan. Cats are far
more likely to recover from serious disease than the dog; however, the cats present much later in the course of the
disease, making it a challenge to proceed ahead with diagnostics and therapeutics in a swift format.
Track A
References
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Pract 20:769–772, 1979.
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21. Scavelli TD, Patnaik AK, Mehlaff CJ, Hayes AA: Hemangiosarcoma in the cat: retrospective evaluation of 31
surgical cases. JAVMA 187:817–819, 1985.
22. Patnaik AK, Liu S-K: Angiosarcoma in cats. J Small Anim Pract 18:191–198, 1977.
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24. Ring RD, Godshalk CP, Smith TA: What is your diagnosis? JAVMA 205:423–424, 1994.
25. Patnaik AK: A morphologic and immunocytochemical study of hepatic neoplasms in cats. Vet Pathol 29:405–
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26. Carb AV: What is your diagnosis? JAVMA 153:556–558, 1978.
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28. MacEwen EG, Mooney S, Brown NO, Hayes AA: Management of feline neoplasms: surgery, immunotherapy
and chemotherapy, in Holzworth J (ed): Diseases of the Cat. Medicine and Surgery. Philadelphia, WB
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30. Mulligan RM: Spontaneous cat tumors. Cancer Res 11:271, 1951.
31. Ervin AM, Junge RE, Miller RE, Thornburg LP: Hemangiosarcoma in a cheetah (Acinonyx Jubatus). J Zoo
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chylothorax. JAAHA 29:78–80, 1993.
34. Hinrichs U, Puhl S, Rutteman GR, et al: Lymphangiosarcomas in cats: A retrospective study of 12 cases. Vet
Pathol 36:164–167, 1999.
35. Swayne DE, Mahaffey EA, Haynes SG: Lymphangiosarcoma and haemangiosarcoma in a cat. J Comp
Pathol 100:91–96, 1989.
36. Ratcliffe HL: Incidence and nature of tumors in captive wild mammals and birds. Am J Cancer 17:116–135,
1933.
37. Gourley IM, Popp JA, Park RD: Myelolipomas of the liver in a domestic cat. JAVMA 158:2053–2057, 1971.
38. Tani K, Goryo M, Okada K: Hepatic myelolipoma in a cat. J Fac Agric Iwate Univ 22:177–180, 1996.
39. Schuh JCL: Hepatic nodular myelolipomatosis (myelolipomas) associated with a peritoneo-pericardial
diaphragmatic hernia in a cat. J Comp Pathol 97:231–235, 1987.
40. Ikede BO, Downey RS: Multiple hepatic myelolipomas in a cat. Can Vet J 13:160–163, 1972.
41. McCaw DL, da Silva Curiel JMA, Shaw DP: Hepatic myelolipomas in a cat. JAVMA 197:243–244, 1990.
42. Lombard LS, Fortna HM, Garner FM, Brynjolfsson G: Myelolipomas of the liver in captive wild felidae. Pathol
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43. Cardy RH, Bostrom RE: Multiple splenic myelolipomas in a cheetah (Acinonyx jubatus). Vet Pathol 51:556–
558, 1978.
44. Wadsworth PF, Jones DM: Myelolipoma in the liver of a cheetah (Acinonyx jubatus). J Zoo Anim Med 11:75–
76, 1980.
45. Munson L, Nesbit JW, Meltzer DGA, et al: Diseases in captive cheetahs (Acinonyx jubatus jubatus) in South
Africa: A 20-year retrospective survey. J Zoo Wildl Med 30:342–347, 1999.
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46. Walzner C: Noduläre lipomatose—"Myelolipome"—in der Mitz des gepards (Acinonyx jubatus). Wien Tierärztl
Mschr 81:24, 1994.
47. Parihar NS, Charan K, Charkravarty IB: Lipomatosis in a hunting cheetah (Acinonyx jubatus). Indian J Vet
Pathol 1:4–5, 1976.
48. Schmähl D, Habs M, Ivankovic S: Carcinogenesis of N-nitrosodiethylamine (DENA) in chickens and domestic
cats. Int J Cancer 22:552–557, 1978.
49. Post G, Patnaik AK: Nonhematopoietic hepatic neoplasms in cats: 21 cases (1983–1988). JAVMA 201:1080–
1082, 1992.
50. Capellaro CEMPDM, Ribeiro LOC, Mueller SBK, Alencar Filho RA: Hepatoma em gato doméstico. Descricáo
de um caso. O Biológico 41:108–110, 1975.
51. Thompson JC, Hickson PC, Johnstone AC, Jones BR: Observations on hypoglycemia associated with a
hepatoma in a cat. N Z Vet J 43:186–189, 1995.
52. Rees CA, Goldschmidt MH: Cutaneous horn and squamous cell carcinoma in situ (Bowen's disease) in a cat.
JAAHA 34:485–486, 1998.
53. Adler R, Wilson DW: Biliary cystadenoma of cats. Vet Pathol 32:415–418, 1995.
54. Trout NJ, Berg RJ, McMillan MC, et al: Surgical treatment of hepatobiliary cystadenomas in cats: Five cases
(1988–1993). JAVMA 206:505–507, 1995.
55. Nyland TG, Koblik PD, Tellyer SE: Ultrasonographic evaluation of biliary cystadenomas in cats. Vet Radiol
Ultrasound 40:300–306, 1999.
56. Hou PC: Primary carcinoma of bile duct of the liver of the cat (Felis catus) infested with Chonorchis sinesis. J
Path Bact 87:239–244, 1964.
57. Peterson SL: Intrahepatic biliary cystadenoma in a cat. Feline Pract 14:29–32, 1984.
58. Feldman BF, Strafuss AC, Gabbert N: Bile duct carcinoma in the cat: three case reports. Feline Pract 1:33–
39, 1976.
59. Sechet B, Regnier A, Diquelou A, et al: Tumeur hépatique primaire chez un chat: discussion a propos d'un
cas de cholangiocarcinome. Revue Méd Vét 142:877–880, 1991.
60. Pastor J, Majo N, Arbona C, et al: Sclerosing adenocarcinoma of the extrahepatic bile duct in a cat. Vet Rec
140:367–368, 1997.
61. Chooi KF, Little PB: Immunoblastic lymphoma and cholangiocarcinoma in a cat. Vet Rec 120:578–579, 1987.
62. Pascal-Tenorio A, Olivry T, Gross TL, et al: Paraneoplastic alopecia associated with internal malignancies in
the cat. Vet Dermatol 8:47–52, 1997.
63. Newell SM, Selcer BA, Girard E, et al: Correlations between ultrasonographic findings and specific hepatic
diseases in cats: 72 cases (1985–1997). JAVMA 213:94–98, 1998.
64. Foley P, Miller L, Graham K, Bellamy J: Cholecystadenocarcinoma in a cat. Can Vet J 39:373–374, 1998.
65. Rehmtulla AJ: Occurrence of carcinoma of the bile ducts: A brief review. Can Vet J 15:289–292, 1974.
66. Minkus G, Hillemanns M: Botryoid-type embryonal rhabdomyosarcoma of liver in a young cat. Vet Pathol
34:618–621, 1997.
67. Lombard LS, Witte EJ: Frequency and types of tumors in mammals and birds of the Philadelphia Zoological
Track A
Garden. Cancer Res 19:127–141, 1959.
68. Hubbard GB, Schmidt RE, Fletcher KC: Neoplasia in zoo animals. J Zoo Anim Med 14:33–40, 1983.
69. Kennedy GA, Strafuss AC: Multiple neoplasia in an aged cougar. J Zoo Anim Med 7:24–26, 1976.
70. McClure HM, Chang J, Golarz MN: Cholangiocarcinoma in a Margay (Felis wiedii). Vet Pathol 14:510–512,
1977.
71. Banner BF, Alroy J, Kipnis RM: Acinar cell carcinoma of the pancreas in a cat. Vet Pathol 16:543–547, 1979.
72. Godfrey DR: A case of feline paraneoplastic alopecia with secondary Malassezia-associated dermatitis. J
Small Anim Pract 39:394–396, 1998.
73. Brooks DG, Campbell KL, Dennis JS, Dunstan RW: Pancreatic paraneoplastic alopecia in three cats. JAAHA
30:557–563, 1994.
74. Kipperman BS, Nelson RW, Griffey SM, Feldman EC: Diabetes mellitus and exocrine pancreatic neoplasia in
two cats with hyperadrenocortism. JAAHA 28:415–418, 1992.
75. Love NE, Jones C: What is your diagnosis? JAVMA 195:1285–1286, 1989.
76. Ditchfield J, Archibald J: Carcinoma of the pancreas in small animals. A report of two cases. Small Anim Clin
1:173–176, 1961.
77. Rowlatt U: Spontaneous epithelial tumours of the pancreas of mammals. Br J Cancer 21:82–107, 1967.
78. Tasker S, Griffon DJ, Nuttall TJ, Hill PB: Resolution of paraneoplastic alopecia following surgical removal of a
pancreatic carcinoma in a cat. J Small Anim Pract 40:16–19, 1999.
79. McEwan NA: Nail disease in small animals. Vet Dermatol Newsl 11:18–19, 1987.
80. Rothwell TLW: Retractile mesenteritis in a cat. Vet Rec 130:492, 1992.
81. Kircher CH, Nielsen SW: Tumours of the pancreas. Bull WHO x53:195–202, 1992.
82. Swann HM, Sweet DC, Michel K: Complications associated with use of jejunostomy tubes in dogs and cats:
40 cases (1989–1994). JAVMA 210:1764–1767, 1997.
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83. Van Der Riet FdStJ, McCully RM, Keen GA, Forder AA: Lymphosarcoma in a cat. J South Afr Vet Assoc 57–
59, 1983.
84. Effron M, Griner L, Benirschke K: Nature and rate of neoplasia found in captive wild mammals, birds and
reptiles at necropsy. J Natl Cancer Inst 59:185–198, 1977.
NOTES:
Track A
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Kitty Oncologic Emergencies: HELP!!!

Introduction
Cancer is a word feared throughout the world, regardless of the species is affected. A diagnosis of cancer
sets in motion feelings of fear and urgency that spur clients to demand rapid response to their concerns by the
veterinary health care team. This heightened level of emotion is first witnessed during the initial diagnosis of cancer
and decision-making process but is often most apparent in emergency situations. In addition, cats hide their clinical
signs until quite late in the disease process and thus are often in a debilitated state by the time cancer therapy
begins; therefore speed and decisiveness are key ingredients of successful emergency care.
It is essential that feline oncologic emergencies be handled with extreme medical care but also with
understanding. When an emergency or urgent situation is noted, the entire veterinary health care team should be
equipped and prepared to provide timely compassionate care to meet the medical and nonmedical needs of patients
and caregivers alike. In some cases, this may mean referring the case to another facility.
There are three types of emergencies:
1. True life-threatening emergencies

2. Medical problems that are perceived as being life-threatening by well-meaning, concerned clients
3. Emergencies of convenience, in which the client wants the cat to be evaluated immediately despite non-life-
threatening emergencies in order to accommodate personal needs or schedule
Regardless of the type of emergency, the following steps should be taken:
1. Determine the primary complaint

2. Evaluate vital signs, including but not limited to:
a. Airway and breathing ability
b. Heart rate, rhythm, and character
c. Body temperature
d. Mucous membrane color and capillary refill time
3. Perform a complete physical examination
4. Obtain a complete history, including prior cancer treatment
When a cat is presented in an emergency situation, blood and urine samples should be collected and an
Track A
intravenous catheter placed as soon as possible. Blood and urine can be submitted at any time to determine
pretreatment parameters based on a complete blood count, biochemical profile, activated clotting time, and
urinalysis. Essential information that is rapidly obtainable and vital for initial decision-making—and that should be
obtained on admission—includes urine specific gravity, packed cell volume, white blood cell count, and blood
glucose.
As soon as a diagnostic and therapeutic plan is initiated, clients should be made aware of every aspect of
the case. Measured, realistic information should be provided as soon as assessments are made and the information
is available. It is also important to provide a cost estimate for initial care as well as updates for ongoing supportive
care. The team approach to care is vital during emergencies. The client is an integral member of the team and, once
empowered with information, is placed in a decision-making role that allows for optimal medical care of the patient
while meeting the emotional needs of the caregiver and family. Ongoing communication allows for an open dialogue
among team members regarding financial limitations, philosophy for continuing critical care in the face of diminishing
hope, and advanced strategies for crisis situations, such as cardiac or respiratory arrest.
Oncologic emergencies, while rare, are potential risks associated with cancer and cancer therapy. Planning
for these uncommon and unwanted problems is essential for a positive outcome. It is important to recognize that the
true “first step” in handling oncologic emergencies is actually prevention. This step occurs prior to the initiation of
treatment and encompasses time spent educating the caregiver about the nature of disease, effects of each
medication to be administered, and the early and often subtle signs that should be dealt with to prevent a true
emergency from ever happening. Similarly, instructions about what clients can do at home to support their cats are
quite helpful. Always remember, the client is perhaps the most important member of the veterinary health care team.
The next step includes educating and empowering the entire veterinary health care team to take an active
role in supporting the patient and the client. The words cancer and cancer therapy often frighten veterinary health
care team members as much as they do the clients. There are emergency situations that are likely to be
encountered. Developing a treatment strategy or “cookbook” approach to these situations empowers the staff to
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intervene quickly and efficiently on behalf of the patient. In addition, providing the health care team with information
that authorizes them to respond to the emotional component of the emergency on the part of the caregiver is also
essential. All members of the health care team must recognize that it is this emotional component that magnifies the
seriousness of almost any health problem.
Neutropenia, Sepsis and Thrombocytopenia

Sepsis
Emergencies are always frightening to clients/caregivers, but when the emergency is related to cancer or
cancer treatment, the intensity of this fear is magnified by the emotional impact imparted by the cancer itself.
Therefore the health care team must act swiftly to both provide medical care for the patient and to meet the
emotional and nonmedical needs of the client. Sepsis due to chemotherapy and cancer-related neutropenia are two
of the more common emergencies handled in feline cancer medicine; bleeding due to thrombocytopenia is much less
common. These conditions are usually preventable by judicious monitoring and appropriate supportive care during
cancer therapy. In addition, caregivers should be educated about the early clinical signs of sepsis, neutropenia, and
thrombocytopenia induced by cancer treatment so that they can seek immediate treatment when these signs occur.
1–7
Sepsis is a common cause of death in human cancer patients, exceeding all other causes combined. As
the popularity of cats increases and the use of chemotherapy and radiation soars in private practice, this situation is
likely to be repeated in feline cancer medicine. Because cats tend to hide their symptoms until late in the disease
process, sepsis may be quite advanced when first recognized and thus requires prompt intervention by the health
care team.
Neutropenia secondary to malignancy or myelodysplasia or resulting from the myelosuppressive effects of
chemotherapy or radiation therapy is a common predisposing factor for the development of sepsis in cats. Septic
shock is the state of circulatory collapse that occurs secondary to overwhelming sepsis and/or endotoxemia; this
syndrome is frequently fatal (mortality rate, 40% to 90%).
The profound systemic effects of septic shock include:

o Vasoconstriction leading to multiple organ failure
o Cardiac dysfunction, in part from lactic acidosis
o Increased vascular permeability, leading to hyperviscosity and hypovolemia
o Liver dysfunction from splanchnic vascular pooling and tissue ischemia
o Acute renal failure
o Worsening neutropenia and thrombocytopenia
o Coagulopathies
o Severe gastrointestinal damage
o Decreased insulin release
o Initial hyperglycemia followed by hypoglycemia
Track A
The bacteria that most commonly cause morbidity and mortality in feline cancer patients arise from the
8
patient’s own flora. The most important thing a clinician can do for the septic feline cancer patient is to quickly
identify the source and type of bacterial infection, initiate therapy with broad-spectrum antibiotics, and provide
appropriate and aggressive supportive care. Minimizing the chance for exposure to, or the opportunity for
development of, resistant strains of bacteria enhances the chance for rapid recovery in response to appropriate
antibiotic therapy. Predisposing factors should be avoided or minimized wherever possible.
Predisposing Factors
o Defects in cellular immunity can cause sepsis in cats with cancer. Cellular immune dysfunction, while
extraordinarily difficult to diagnose in cats, may be due to an underlying cause or the result of administration
of antineoplastic agents and/or corticosteroids. These defects may lead to various bacterial, mycobacterial,
fungal, and viral infections. Humoral immune dysfunction is also associated with an increased prevalence of
sepsis in human cancer patients and may cause similar problems in animals. Agammaglobulinemic or
hypogammaglobulinemic cats are suspected to be susceptible to infections. Multiple myeloma and chronic
lymphocytic leukemia are common neoplasms associated with humoral immune dysfunction in humans and
are likely causes in cats as well.
o Neutropenia may be caused by the myelosuppressive effects of chemotherapy, which can be categorized as
high, moderate, or mild. The nadir (lowest part of the white blood cell count) varies by drug.
o Splenectomized cats are susceptible to overwhelming sepsis when they are infected with a strain of
encapsulated bacteria against which they have not made antibodies.
o Indwelling vascular or urinary catheters and chest and endotracheal tubes have been associated with an
increased prevalence of sepsis. The longer a catheter is present, the higher the probability for infection,
especially in neutropenic cats.
o Frequent acquisition of blood samples greatly increases the risk of sepsis in cats with cancer.
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o Antibiotic administration may lead to increased susceptibility to increasingly resistant strains of organisms.
o Prolonged hospitalization can result in serious consequences, in part because the patient is continually
exposed to bacterial strains that are resistant to the antibiotics most commonly used in that practice.
o Malnutrition is a serious cause of debilitation and decreased resistance to bacterial infection, especially in
cats with neutropenia.
o Cats with neurologic dysfunction and nonambulatory patients (regardless of cause) are at increased risk for
sepsis.
Whenever possible, these risk factors must be avoided or minimized and associated problems recognized
and corrected early to reduce the probability of sepsis. The first approach for clinicians and clients is to understand
the myelosuppressive effects of various drugs. Clients and the veterinary health care team should be encouraged to
be more vigilant for the clinical signs associated with neutropenia and thrombocytopenia around the time of the nadir
for the drug being used. By monitoring complete blood counts (CBCs) at the appropriate times, especially early in the
course of chemotherapy, veterinarians have a better idea of how low the white blood cell (WBC) count is actually
dropping. If the count appears too low (below 1,000/µl) or the patient becomes even mildly symptomatic, subsequent
dose reduction of that drug should be considered.
Additional steps can be taken to minimize the risk of sepsis in cats with cancer. One logical step is to
minimize the administration of immunosuppressive drugs, especially corticosteroids. Splenectomized cats being
treated for cancer should be watched carefully for complications, including sepsis. The risk of catheter-induced
sepsis can be minimized by using aseptic technique and by placing a new catheter in a new site every 2 to 3 days.
Strict aseptic procedures should be used, especially with myelosuppressed cats and those with neurologic
dysfunction; the latter have a much higher risk for developing sepsis. The use of semipermanent indwelling catheters
in patients with cancer may be safe if strict aseptic procedures are followed by caregivers and health care
professionals. The duration of hospitalization should be limited as much as possible to limit exposure to resistant
bacteria.
Diagnosis
Cats presented with septic shock secondary to neutropenia require immediate intervention and careful client
support. Diagnostic and therapeutic interventions must begin concurrently for the patient’s benefit. The differential list
for neutropenia is quite extensive.
The diagnosis of septic shock begins with the physical examination and while a catheter is placed and blood
samples are acquired. Mucous membrane color can be difficult to ascertain in cats, although brick-red mucous
membranes may be noted in some cats with septic shock.
1–6
The following signs may be identified in cats in the hyperdynamic state of septic shock:
o Tachycardia
o Short capillary refill time
o Gastrointestinal signs
Track A
o Altered mentation
o Decreased blood pressure
1–6
End-stage signs reflect a hypodynamic state and include:
o Hypothermia
o Mucous membrane pallor
o Marked mental depression
o Bloody diarrhea
o Signs of multiple organ failure
Thrombocytopenia and neutropenia are often identified during the course of septic shock. Hyperglycemia is
an early finding and is often followed by hypoglycemia. Metabolic acidosis is common.
Blood and urine collected at the time of initial presentation can be very helpful for supporting a diagnosis of
septic shock. At a minimum, samples should be obtained for a CBC, biochemical profile, and urinalysis. Other tests
may also be indicated.
The absence of circulating neutrophils affects many of the commonly used clinical, laboratory, and
radiographic findings that may normally suggest a localized or systemic infection. For example, urinalysis results may
not demonstrate pyuria in cats with neutropenia despite the presence of an urinary tract infection. Likewise, without a
neutrophilic infiltrate, the presence of which would otherwise be responsible for many of the radiographic changes
associated with pneumonia, chest radiographs often appear “normal” even in the presence of significant pneumonia.
Urine and blood cultures should always be obtained, even though they may be negative and results may not
be available for a significant amount of time. Appropriate broad-spectrum antibiotics and combinations must be
available for immediate parenteral administration. Culture results will guide follow-up oral antibiotic selection.
245
All suspicious sites should be cultured, including but not necessarily limited to:
o Blood: Two (preferably four) sets of blood cultures (aerobic and anaerobic) should be acquired. However,
clinicians must be aware of the total volume of blood collected, including blood for hemograms, biochemical
profiles, and other tests, because these cats almost always have some degree of anemia associated with
chronic disease. The interval at which samples should be collected is controversial, although sampling every
20 to 30 minutes before antibiotic therapy is initiated may be adequate. At least 2 ml of blood should be
injected into appropriate culture containers.
o Catheter: If central venous catheters are present, cultures of the port should be obtained. Ideally, culture
bottles containing an antibiotic-binding resin or other antibiotic-binding substance should be used for patients
receiving IV antibiotics.
o Urine: A urine specimen collected via cystocentesis should be acquired from each patient.
o Cerebrospinal fluid (CSF): When neurologic signs are present, a sample of CSF should be obtained and
cultured appropriately. CSF should be sent for Gram staining, bacterial culture, cell count and differential,
and glucose and protein determination. A cryptococcal antigen titer or India ink preparation should be
performed in suspect cases. Acid-fast stains and culture are probably not indicated routinely.
o Stool: For cats with diarrhea, appropriate cultures should be done for clostridial bacteria, including assays for
endotoxin if indicated.
o Lung: Thoracic radiographs and a transendotracheal wash should be obtained, especially from patients
showing any signs of respiratory difficulty, such as increased respiratory effort or a cough.
Other diagnostic studies that should be considered include:

o MDB, including CBC with differential, biochemical profile, urinalysis, and thoracic and abdominal radiographs
to detect signs of infection
o Abdominal ultrasonography to evaluate for pancreatitis, abscesses, abdominal effusion, and the like
o Echocardiography to identify the presence of valvular endocarditis
o Bronchoscopy, if pulmonary disease is suspected
o Skin biopsy, if deep cutaneous infection is identified
o Bone marrow aspiration or biopsy to determine the cause and severity of neutropenia
o Percutaneous or laparoscopic-guided liver biopsy or aspiration to evaluate for hepatic infection or
abscessation
o Exploratory laparotomy in select cases when other, less invasive tests are unsuccessful yet there is clinical
evidence of abdominal disease
o Blood gas analysis
1–8
Treatment
Treatment for septic shock should begin as soon as the condition is suspected, typically when a cat is initially
presented for an acute emergency condition. Treatment for septic, neutropenic cats is primarily directed at: restoring
adequate tissue perfusion, improving metabolic alterations, and controlling systemic infection.
Track A
Restoring Adequate Tissue Perfusion

Standard therapy includes administering crystalloid solutions and antibiotics. Although the use of hypertonic
solutions for the treatment of shock is being investigated, balanced electrolyte solutions are cited as “the first line of
therapy” in most feline texts. The initial infusion rate for critical cats is 40 to 60 ml/kg IV for 1 hour, then 10 to 12
ml/kg/hour thereafter. The administration rate should then be adjusted to meet the needs of each cat as determined
by monitoring body weight, heart and respiratory rates, central venous pressure, ongoing losses (e.g., vomiting and
diarrhea), and urine output. During that first hour of fluid administration, it is vitally important to monitor for evidence
of fluid overload at 15 minute intervals and adjust appropriately.
Improving Metabolic Alterations

When choosing fluid types, some authorities prefer a fluid that does not contain lactate (e.g., Normosol R,
Plasmalyte; both use acetate and gluconate as buffers); lactate must be metabolized to bicarbonate by a functional
liver, but shock and sepsis may impair liver function. Dextrose should be included in fluids when systemic
hypoglycemia is identified.
Preventing or Controlling Infection

Asymptomatic cats with fewer than 1,000 neutrophils/µl should be started on prophylactic antibiotics.
Trimethoprim-sulfa (7.5 mg/kg bid PO) is often recommended for prophylactic therapy in asymptomatic neutropenic
patients. Neutropenic cats in septic shock should be started on IV fluids and IV antibiotic therapy as soon as samples
for bacterial cultures have been acquired.Reevaluation of the initial antibiotic regimen is mandatory when the identity
and sensitivity patterns of the bacteria become available. For gram-negative infections, a combination of two
antibiotics effective against the isolated organism are recommended.
246
Initially, broad-spectrum antibiotic therapy—often a combination of an aminoglycoside plus penicillin or second-
generation cephalosporin (e.g., cefoxitin, cefamandole, cefaclor, cefuroxime, cefonicid, ceforanide, cefotetan,
ceftezole)—is commonly used in sepsis. The antibiotics should be changed if the infection does not respond within
24 hours. For gram-negative organisms, aminoglycosides, quinolones, or aztreonam may be used. Extended-
spectrum penicillins (e.g., ticarcillin, carbenicillin, azlocillin, piperacillin sodium, mezlocillin third-generation
cephalosporins (e.g., cefotaxime, moxalactam, cefoperazone, ceftizoxime, ceftriaxone, ceftazidime, cefixime), and
imipenem with cilastatin sodium have sufficiently broad spectrums to be used alone. Cats receiving aminoglycosides,
particularly gentamicin, should be monitored for nephrotoxicity via urinalysis (urine sediment should be examined for
the presence of casts) and measurement of blood urea nitrogen and creatinine concentrations, and it should be
ensured that they are receiving parenteral fluids.
Other treatments include:

o Corticosteroids: Steroids remain controversial in the treatment of septic shock. Recommended doses for
patients in shock are hydrocortisone at 300 mg/kg, methylprednisolone or prednisone at 10 to 30 mg/kg, or
dexamethasone at 4 to 8 mg/kg. Short-term use (i.e., less than 2 days of massive doses) has fewer adverse
effects than long-term use.
o Glucose: If hypoglycemia is present, glucose can be given at 0.25 g/kg IV bolus, followed by infusions of
2.5% to 10% glucose solutions as needed to maintain normal blood glucose levels.
o Bicarbonate: Bicarbonate can be given if severe metabolic acidosis is present. The amount of bicarbonate
to administer can be calculated [base deficit × (0.3 × bodyweight in kg)] or estimated (mild, moderate, or
severe acidosis is treated with 1, 3, or 5 mEq bicarbonate/kg IV, respectively). Bicarbonate should be given
via slow IV (i.e., over 20 minutes or more).
o Neutrophil-Rich Transfusions: These transfusions have not been associated with beneficial responses in
controlled trials. In addition, transfusion reactions and allosensitization to specific granulocyte antigens may
occur, and increased prevalence of severe pulmonary reactions may be noted.
o Hematopoietic Growth Factors: Canine recombinant granulocyte colony-stimulating factor (rcG-CSF; 5
µg/kg/day SQ) and canine recombinant granulocyte-macrophage colony-stimulating factor (rcGM-CSF; 10
µg/kg/day SQ) have been associated with an increased rate of myeloid recovery in dogs and cats with
neutropenia. These hematopoietic growth factors increase cell numbers and enhance neutrophil function but
are not yet available commercially. Human recombinant G-CSF and GM-CSF are commercially available;
however, long-term use may induce antibody formation to the protein. Of the two human recombinant
proteins, rhG-CSF induces the most profound increase in canine and feline neutrophil numbers before
development of antibodies is noted.
o Transfusions of Fresh, Whole Blood
o Other Options: Tumor necrosis factor antiserum, antibody to tumor necrosis factor, interleukin and
interferon therapy, pooled immunoglobulin preparations, and monoclonal antibodies to neutralize endotoxin
may be future treatments of choice.
Track A
Thrombocytopenia
The most common causes of decreased platelet count are the cytotoxic effects of chemotherapeutic agents,
bone marrow infiltration by a malignant process, and feline infectious peritonitis. If a chemotherapeutic agent induces
bone marrow suppression resulting in cytopenia, thrombocytopenia usually occurs a few days after neutropenia but
before red blood cell numbers decline. Commonly identified abnormalities include a mixed hemostatic defect
compatible with disseminated intravascular coagulation (DIC), isolated prolongation of the activated partial
thromboplastin time (APTT), and prolongation of both the APTT and one-stage prothrombin time (OSPT).
Thrombocytopenia can occur in any cat with cancer that receives myelosuppressive chemotherapeutic
agents. Drugs such as vincristine, bleomycin, and prednisone do not cause as significant a thrombocytopenia as do
some of the more highly myelosuppressive agents (e.g., doxorubicin). Compared to many other myelosuppressive
drugs, cyclophosphamide induces less suppression in platelet numbers. Cats with bone marrow infiltration by a
malignant process are more sensitive to the cytotoxic effects of chemotherapeutic agents that can result in
thrombocytopenia. Other conditions that affect the bone marrow are likely to make it more sensitive to cytotoxic
agents. Tumors that are frequently associated with coagulopathies may cause consumptive thrombocytopenia. In
addition, hypersplenism and chronic bleeding of any cause can result in a decrease in the number of platelets.
Diagnosis
Because they mask early symptoms of illness, cats are often presented late in the course of clinical disease.
This is true for diseases or conditions that result in thrombocytopenia. Clinical signs include, but are not limited to,
bleeding diatheses, melena, and weakness. The blood loss can occur from/into any organ and result in multisystemic
247
abnormalities. An acute decline in the number of platelets may result in the development of clinical signs at higher
platelet counts than when the decline in platelets is much slower. Therefore, if there is any suspicion that
thrombocytopenia may be present (gingival hemorrhage, petechial or ecchymotic hemorrhages, or any of the
previously mentioned symptoms), proactive interventional and diagnostic measures should be taken after the
physical examination is performed. A catheter should be placed and blood obtained with a small gauge needle for
routine blood work (CBC with platelet count, biochemical profile, T4, and FeLV/FIV testing), and a urinalysis should
be performed as well to complete a minimum database. Diagnosis is confirmed by obtaining platelet counts and by
examining bone marrow aspiration or biopsy specimens. Bone marrow evaluation is essential and helps the clinician
determine the cause of the thrombocytopenia. Clotting profiles (e.g., APTT, OSPT, and fibrin degradation products
[FDPs]) may help determine if the thrombocytopenia is the result of a coagulopathy, such as DIC.
Therapy
Thrombocytopenia-related clinical signs can be exacerbated when drugs that affect platelet function are
administered during the time of overt or impending thrombocytopenia. Therefore aspirin and aspirin-like drugs should
be withheld from cats with thrombocytopenia. In addition, the use of heparinized saline for catheter maintenance can
be a problem in some patients if multiple catheter “flushes” are performed.
Cats with thrombocytopenia should be kept quiet, and care should be taken during handling. Vincristine (0.5
2 8
mg/m body surface area) can be administered IV to induce premature release of platelets from megakaryocytes.
Platelet counts increase 4 days after vincristine is given. Where available, platelet transfusions may be administered
to specific cats that are (or have a high likelihood of) bleeding uncontrollably. Administering each unit of platelets with
30 to 60 ml of plasma is recommended. In cats with acute bleeding that is not responsive to other treatments of
2 9
procedures, hemostatic epsilon aminocaproic acid can be given IV or PO (250 mg/m q6h). Dose reduction should
occur with the next administration of the same chemotherapeutic agents.
Acute Tumor Lysis Syndrome

Acute tumor lysis syndrome (ATLS) is an underreported, rare condition characterized by acute collapse—
possibly leading to death—soon after administration of a chemotherapeutic agent or radiation therapy for a
1–3
chemosensitive- or radiation-sensitive tumor. ATLS most often occurs shortly after the treatment of lymphoma and
lymphoid leukemia or may occur after effective chemotherapy in cats with rapidly growing, bulky, chemosensitive
tumors. Cats commonly present with a brief history of acute decompensation, sometimes to the point of imminent
death. Rapid diagnosis and therapy are essential to reduce mortality.
The actual pathophysiology of ATLS in cats has not been studied and is therefore unknown. In humans, and
probably in cats, rapid tumor lysis may cause an acute release of intracellular phosphate and potassium, which leads
to hypocalcemia, hyperkalemia, and hyperphosphatemia. Hyperuricemia is also seen in humans who develop ATLS.
ATLS is most common in patients with lymphoma or leukemia, partly because the intracellular concentration of
1
phosphorus in human lymphoma and leukemic cells is 4 to 6 times higher than in normal cells. Unpublished clinical
Track A
experience suggests that ATLS is most likely to occur in cats with some degree of volume contraction and a large
tumor mass (particularly stage IV or V lymphoma) that rapidly responds to cytolytic therapy. In addition, septic cats
and those with extensive neoplastic disease that infiltrates the parenchyma of organs are predisposed to ATLS. This
condition may be identified within 48 hours after chemotherapy or radiation therapy is first administered.
Diagnosis
Cats with suspected ATLS present with clinical signs similar to those seen in neutropenic and/or septic cats
and are often diagnosed following acute collapse and decompensation hours to days after the administration of
chemotherapy. To reduce morbidity and mortality, rapid diagnosis of and therapy for ATLS are essential. Cats with
ATLS may have cardiovascular collapse, vomiting, diarrhea, and ensuing shock. Hyperkalemia may result in
bradycardia with diminished P wave amplitude and spiked T waves on an electrocardiogram. Biochemical analysis of
blood may confirm the presence of hypocalcemia, hyperkalemia, and hyperphosphatemia. If several hours have
passed after decompensation, however, hyperkalemia and hyperphosphatemia may have self-corrected.
Hyperuricemia is seen in humans with ATLS but has not been identified in cats. In the presence of elevated serum
phosphate levels, hypocalcemia develops as a result of calcium and phosphate precipitation. Without effective
treatment, cardiovascular collapse, shock, or renal failure may occur in patients with this syndrome; blood urea
nitrogen and creatinine concentrations should therefore be monitored closely.
Treatment
The best treatment is prevention. Because the kidneys are the main source of electrolyte excretion,
metabolic abnormalities may be exacerbated in cats with renal dysfunction. Identification and correction of any
volume depletion or azotemia prior to initiation of therapy may reduce the risk of ATLS; chemotherapy should be
delayed until metabolic disturbances such as azotemia are corrected. If ATLS is identified, the condition should be
248
treated with aggressive crystalloid fluid therapyand careful monitoring of electrolytes and renal parameters. Further
chemotherapy should be withheld until the patient is clinically normal and all biochemical parameters have stabilized.
Metabolic Emergencies
Hypercalcemia
1–10
Hypercalcemia is the most common metabolic emergency in oncology. Lymphoma is the leading cause of
hypercalcemia in cats, although hypercalcemia occurs much less often in cats with lymphoma than in dogs with
lymphoma. Other causes of hypercalcemia in cats include multiple myeloma, squamous cell carcinoma, mammary
adenocarcinoma, and primary hyperparathyroidism. Parathyroid carcinomas or adenomas are rare malignancies
associated with intractable hypercalcemia caused by elevated parathyroid hormone (PTH) levels. A parathyroid
hormone-related peptide (PTH-rp) is most commonly associated with hypercalcemia in dogs and probably in cats as
well, although the assay for PTH-rp is not as routinely performed or as reliable in feline medicine as in canine
medicine. It has been suggested that bone metastasis can be associated with hypercalcemia, but this is rare in feline
medicine.
One recent retrospective study was conducted to characterize the diseases, clinical findings, and
clinicopathologic and ultrasonographic findings associated with hypercalcemia (serum calcium concentration above
7
11 mg/dl) in 71 cats. The three most common diagnoses were neoplasia (21 cats), renal failure (18 cats), and
urolithiasis (11 cats). Primary hyperparathyroidism was diagnosed in 4 cats. Lymphoma and squamous cell
carcinoma were the tumors diagnosed most frequently. Calcium oxalate uroliths were identified in 8 of 11 cats with
urolithiasis. Cats with neoplasia had a higher serum calcium concentration (13.5 ± 2.5 mg/dl) than cats with renal
failure or urolithiasis and renal failure (11.5 ± 0.4 mg/dl; p <.03). Serum phosphorus concentrations were higher in
cats with renal failure than in cats with neoplasia (p <.004).
Emergency malignancy-induced hypercalcemia is characterized by clinical signs associated with a
decreased sensitivity to antidiuretic hormone (ADH) by the distal convoluted tubules and collecting ducts and the
vasoconstrictive properties of calcium that result in decreased renal blood flow and a reduced glomerular filtration
1–4
rate. The renal epithelium undergoes degenerative changes, necrosis, and calcification. These physiologic and
pathologic changes result in progressive renal disease, noted clinically as polyuria and polydipsia followed by
vomiting, hyposthenuria, and dehydration. Calcium may also affect the gastrointestinal, cardiovascular, and
neurologic systems directly and cause anorexia, vomiting, constipation, bradycardia, hypertension, skeletal muscle
weakness, depression, stupor, coma, and seizures.
Diagnosis
++
Other diagnostic differentials that must be considered in cats presented for true hypercalcemia (Ca above
11 mg/dl) include laboratory or interpretation error, hyperproteinemia from dehydration, acute renal failure, vitamin D
and calcium toxicosis, granulomatous disorders, nonneoplastic bone disorders, hypoadrenocorticism, and true
2,5,6
hyperparathyroidism.
Track A
It is important to interpret calcium levels in relation to serum albumin and blood pH. The following formula
takes albumin into account:
adjusted calcium (mg/dl) = [calcium (mg/dl) – albumin (g/dl)] + 3.5
Acidosis increases the free, ionized fraction of calcium and can magnify the observed clinical signs
associated with hypercalcemia.
Serial serum calcium, electrolytes, blood urea nitrogen (BUN), and creatinine levels should be measured in
all hypercalcemic patients. While controversial, a finding of elevated immunoreactive PTH levels in association with
hyperphosphatemia may suggest ectopic hormone production. The PTH-rp assay is unreliable in cats but may be
helpful in some situations. Cats with multiple myeloma may have elevated calcium levels secondary to abnormal
calcium binding to a paraprotein without an elevation in ionized calcium, and malnourished cats with
hypoalbuminemia may have symptoms of hypercalcemia despite normal serum calcium levels.
2,5,6,11–17
Treatment
Treatment of a hypercalcemic emergency depends on the severity of the clinical signs and whether renal
disease is present. Appropriate management almost always entails the use of IV saline in volumes exceeding daily
0.75
maintenance (more than 132 ml/kg /day [more than approximately 44–66 ml/kg/day] plus enough to replace
exogenous losses from vomiting and diarrhea, plus replacement fluids for dehydration). Potassium depletion should
be prevented by adding potassium chloride to fluids based on serum potassium levels.
The rate of IV potassium should not exceed 0.5 mEq/kg/hour. Cats should be watched carefully for signs
consistent with overhydration and congestive heart failure. If hypercalcemia is the result of a malignancy, effective
249
antitumor therapy should be initiated as soon as possible. Thiazide diuretics or vitamins A and D may elevate
calcium levels and thus should never be used in these cats.
The most commonly used drugs for managing cats with hypercalcemia include:
o Furosemide (1 to 4 mg/kg bid, IV or PO) and IV bisphosphonates (e.g., etidronate, disodium pamidronate)
may be used in addition to saline diuresis. IV or PO bisphosphonates have rapid hypocalcemic effects due to
their inhibition of osteoclast activity.
o Gallium nitrate produces concentration-dependent reductions in osteolytic response to parathormone and
certain other types of lymphokines that cause hypercalcemia. Gallium nitrate infused at doses of
2
approximately 100 mg/m /day for 5 consecutive days successfully reduces high calcium levels in 86% of
8,9
human patients.
o Mithramycin, a chemotherapeutic agent that decreases bone resorption by reducing osteoclast numbers
and activity, also has been shown to be effective in humans. Because mithramycin is a sclerosing agent, it
must be given as a bolus (25 µg/kg IV once or twice weekly) through a newly placed line. If extravasation
occurs, ulceration and fibrosis will develop. Mithramycin has not been used extensively in dogs or cats;
twice-weekly dosing may be required in refractory patients.
o Salmon calcitonin (4 to 8 MRC U/kg SC) may also be used in refractory patients. Calcitonin inhibits bone
resorption and thus causes serum calcium levels to fall within hours of administration. When administered at
higher dosages than are clinically applicable (40 U/kg), salmon calcitonin may result in hypocalcemia for
several days.
o Corticosteroids are effective for treating hypercalcemia. Corticosteroids block bone resorption caused by
osteoclast-activating factor, increase urinary calcium excretion, inhibit vitamin D metabolism, and increase
calcium absorption after long-term use. To be effective, high doses are generally required for several days.
Steroids should not be used until tissue diagnosis is made, primarily because lymphomas are the most
common cause of malignancy-associated hypercalcemia and the indiscriminate use of steroids could make
diagnosing lymphoma difficult to impossible.
Most cats can be effectively treated with hydration, antitumor therapy, and administration of hypocalcemic-
inducing agents, such as mithramycin, calcitonin, or corticosteroids. Serum calcium should be monitored at least
twice weekly.
Hyponatremia/Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH)
The emergency situation caused by the syndrome of inappropriate antidiuretic hormone secretion (SIADH) is
6–10
a rare and underrecognized, albeit important, cause of true hyponatremia in cancer patients. As the name implies,
SIADH is the presence of excessive quantities of ADH secondary to a malignancy. Affected cats have a low plasma
osmolality despite inappropriately high urine sodium concentrations. Because this situation can also occur in patients
with renal disease, hypothyroidism, or adrenal insufficiency, these disorders must be excluded to confirm a diagnosis
Track A
of SIADH.
SIADH may be caused by a malignancy or drug that results in renal activation or enhanced release of ADH.
SIADH has been identified in cats with lymphoma.
6–9
Drugs in feline medicine that can cause this condition include :
o Chlorpropamide
o Vincristine
o Vinblastine
o Cyclophosphamide
o Opiates
o Thiazide diuretics
o Barbiturates
o Isoproterenol
o Mannitol
o Morphine
o Other diuretics
6–9
The abrupt withdrawal of steroids may also cause SIADH. When hyponatremia develops rapidly or serum
sodium falls below 115 mg/dl, cats may develop mental status abnormalities, confusion, or coma. Serum and urine
electrolytes, osmolality, and creatinine levels should be measured when SIADH is suspected.
250
Diagnosis
Clinical signs include anorexia, nausea, and muscle stiffness progressing to confusion, neurologic signs,
coma, and death. In patients with SIADH, urine sodium concentration is inappropriately high for the level of
hyponatremia. Urine osmolality is therefore greater than plasma osmolality, but the urine specific gravity is never
maximally dilute. BUN is usually low because of volume expansion. Hypophosphatemia may be noted. Adrenal and
thyroid function should be normal.
Treatment
In an emergency setting, initial treatment should be directed at resolution of hyponatremia. Fluids should be
restricted to ensure that the cat receives only the amount needed to maintain normal hydration and to keep serum
sodium concentration within normal levels. In emergencies, demeclocycline may correct hyponatremia by reducing
ADH stimulus for free water reabsorption at the collecting ducts. The most common side effect of demeclocycline is
nausea and vomiting. Lithium carbonate and phenytoin have some use in treating SIADH. Hypertonic sodium
chloride (3% to 5%) can be used in an emergency, but may result in fluid and circulatory overload if not used
carefully. Furosemide can be administered concurrently with hypertonic saline to reduce volume overload. It should
be noted that rapid correction of hyponatremia may lead to neurologic damage. The following formula may help to
10
determine the approximate amount of sodium needed to correct hyponatremia :
Na for replacement (mEq) = (desired serum sodium [mEq/L] – observed serum sodium [mEq/L]) × body
weight (kg) × 0.6
Hypoglycemia
Fasting hypoglycemia in the face of hyperinsulinemia occurs most commonly with insulinomas; although
6–12
other tumors of the liver (e.g., hepatomas, carcinomas) have also been associated with this condition. Liver
disease (including glycogen storage diseases) and sepsis may mimic hypoglycemia of malignancy. In addition,
because red blood cells (RBCs) can metabolize glucose rapidly, delay in separating RBCs from serum may lead to
artificially reduced serum glucose concentrations.
Clinical Signs
Before they present with seizures, coma, and impending death, most cats have a history of exhibiting signs
of fatigue, weakness, dizziness, and confusion associated with paroxysmal lowering of blood glucose levels.
Neurologic signs associated with hypoglycemia may mimic other central nervous system (CNS) abnormalities, such
as brain tumors, brain trauma, meningitis, or metabolic encephalopathy.
Insulin-producing tumors can be diagnosed by identifying elevated insulin levels in association with low blood
glucose concentrations. In some cases, the identification of malignancy-associated hypoglycemia may require
11
periodic sampling during a 72-hour fast. Diagnosis is confirmed when blood glucose is dramatically reduced while
insulin levels are elevated. Although controversial, the amended insulin:glucose ratio has been advocated as a
Track A
12
method to help diagnose insulin-producing tumors in domestic cats :
(serum insulin [µU/ml] × 100)

___________________________________ = amended insulin:glucose ratio
(serum glucose [mg/dl] – 30)
Values above 30 suggest a diagnosis of insulinoma or other insulin-producing tumor.

6–12
Treatment
In an emergency situation, medical management is often necessary before, during, and after definitive
therapy, especially for insulinomas, which have a high metastatic rate. Glucose-containing fluids (2.5% to 5%
dextrose in 0.9% NaCl or another isotonic crystalloid solution) should be administered to meet fluid requirement
needs and maintain blood glucose concentrations within acceptable limits. It should be noted, however, that the
administration of glucose may trigger the tumor to release more insulin, and thus a constant rate infusion of glucose
to maintain normal serum glucose levels is preferred to intermittent administration of high-dose boluses. A cat with
hypoglycemia (above 60 mg/dl) and experiencing seizures should be treated with 0.5 g dextrose/kg administered IV
slowly over 3 to 5 minutes. Repeat doses may be needed.
Prednisone (0.5–2.0 mg/kg divided bid PO) is often effective in elevating blood glucose levels by inducing
hepatic gluconeogenesis and decreasing peripheral utilization of glucose. Diazoxide (10–40 mg/kg divided bid PO)
may effectively elevate blood glucose levels by directly inhibiting pancreatic insulin secretion and glucose uptake by
tissues, enhancing epinephrine-induced glycogenolysis, and increasing the free fatty acid mobilization rate. The
hyperglycemic effects of diazoxide can be potentiated by concurrent administration of hydrochlorothiazide (2–4
mg/kg daily PO). Propranolol (0.2–1.0 mg/kg tid PO), a β-adrenergic blocking agent, may also be effective in
251
increasing blood glucose levels by inhibition of insulin release through the blockade of β-adrenergic receptors at the
level of the pancreatic β cell, inhibition of insulin release by membrane stabilization, and alteration of peripheral
insulin receptor affinity. Combined surgical and medical management of pancreatic tumors has been associated with
remission periods of 1 or more years. Once the patient is stabilized, surgical extirpation may be the best treatment for
a hypoglycemia-causing tumor. Because many tumors (including insulinomas) that induce hypoglycemia as a
paraneoplastic syndrome are malignant, surgery often is not curative. A partial pancreatectomy may be indicated for
insulinomas; iatrogenic pancreatitis and diabetes mellitus are recognized complications.
Chemotherapy-Induced Anaphylaxis and Hypersensitivity
Although anaphylaxis or an anaphylaxis-like reaction can occur with any drug, these potentially life-
threatening reactions usually happen soon after the administration of L-asparaginase. Hypersensitivity reactions can
1 2
likewise occur with any drug but are most commonly associated with administration of doxorubicin, taxol, and
3
etoposide.
L-Asparaginase is well known for inducing anaphylaxis, hemorrhagic pancreatitis, diabetes mellitus, and
coagulopathies in cats, dogs, and humans; 48% of dogs given L-asparaginase intraperitoneally (IP) developed
4
adverse effects, and 30% of these dogs exhibited signs of anaphylaxis. These findings are similar to those in
5
children given L -asparaginase intravenously (IV). The same study showed that intramuscular (IM) administration of
the drug completely eliminated signs associated with anaphylaxis without reducing remission rates.
L-Asparaginase-induced anaphylaxis and hypersensitivity are common because of enzyme immunogenicity.
Anaphylaxis is usually caused by IgE-mediated mast cell degranulation; however, certain substances (e.g., bacterial
and fungal cell walls) can trigger anaphylaxis by activating the alternate complement pathway. During the activation
of this alternate pathway, complement factors C3a and C5a—known potent anaphylatoxins capable of degranulating
6
mast cells and basophils —are formed. Although the exact mechanism of L-asparaginase-induced anaphylaxis in
cats is largely unexplored, induction of anaphylaxis in children with acute lymphoblastic leukemia is believed to result
7
from complement activation induced by formation of immune complexes of L-asparaginase and specific antibodies.
Anaphylaxis usually occurs within seconds to minutes after L-asparaginase administration.
The hypersensitivity reaction secondary to doxorubicin therapy is believed to be related to mast cell
degranulation. Cremophor EL and polysorbate 80, the carriers used in formulations of paclitaxel and etoposide,
respectively, are responsible for the hypersensitivity reaction induced by these drugs.
One predisposing factor for anaphylaxis secondary to L-asparaginase or other drug therapy is a history of
prior exposure to the drug. Because L-asparaginase is a ubiquitous bacterial product in mammals, anaphylaxis is
possible after the first administration. In addition, anaphylactic and hypersensitivity reactions are worse in cats with a
preexisting condition that results in a buildup of mast cells and eosinophils prior to drug treatment.(e.g., atopy). As
mentioned, a drug’s administration route may be a contributing factor to the development of anaphylactic or
hypersensitivity reactions.
Track A
Diagnosis
The most common clinical signs associated with drug-induced anaphylaxis are acute collapse and
cardiovascular failure, which can lead to shock and death. The event usually occurs within minutes after a parenteral
injection of the offending drug, although anaphylactic reactions that occur hours to days after drug therapy have been
reported. Affected cats are generally pale and weak and usually exhibit such cardiac signs as bradycardia or
tachycardia and a rapid, thready pulse. Mucous membranes are typically pale to cyanotic. Peripheral extremities are
often cool to the touch, and blood pressure is low. Other causes of acute decompensation and collapse should be
ruled out using the results of a minimum database and cardiac work-up.
Hypersensitivity reactions may result in profound pruritus during or after drug administration. Pruritus may
result in head shaking, and there may be swelling of the ears, lips, or paws or near the injection site or area being
treated. The erythematous reaction usually lasts for the duration of treatment. Occasionally, the edematous and
erythematous reaction may last for hours after the treatment is finished.
6,8,9
Therapy
Prevention
Hypersensitivity reactions secondary to the administration of doxorubicin can be almost completely
eliminated by diluting the drug in 50 ml of 0.9% NaCl and administering over 20 to 40 minutes. With this method, the
a
incidence of hypersensitivity reaction is believed to be reduced to less than 3% in cats. (Even if the possibility of a
hypersensitivity reaction is low, some clinicians recommend pretreatment with diphenhydramine and glucocorticoids
to further reduce the prevalence of hypersensitivity reactions.
Reactions secondary to the carriers in paclitaxel and etoposide can be reduced by slowing the infusion rate
and pretreating with dexamethasone (1–2 mg/kg IV), diphenhydramine (2–4 mg/kg IM), and cimetidine (2–4 mg/kg IV
252
slowly) 1 hour before infusion of the chemotherapeutic agent. If a reaction is noted, the infusion can be discontinued
temporarily until the patient is more comfortable and symptoms have abated.
Although L-asparaginase is notorious for inducing anaphylaxis, this is uncommonly reported in the cat. IV or
IP administration is far more likely to induce anaphylaxis than IM or SC administration. Data in dogs suggest that the
drug is more effective for inducing remission when given IM instead of SC.
Treatment
Anaphylaxis is a potentially fatal condition and should be treated immediately with supportive care, fluids,
glucocorticoids, H1 receptor antagonists, and epinephrine.If anaphylaxis occurs, the responsible drug should not be
administered to the patient again. The clinical approach to anaphylaxis in the feline cancer patient is summarized
elsewhere.
Hypersensitivity reactions can be treated by terminating drug therapy. Reactions usually subside within
minutes. The cat can then be treated with H1 receptor antagonists before reinitiating drug treatment at a much slower
rate.
Extravasation of Chemotherapeutic Agents
Many chemotherapeutic agents are known to induce significant tissue injury after extravasation. Some of
these agents are severe, irreversible vesicants whereas others induce tissue irritation.
Preventing extravasation is the best “management” method. Atraumatic placement of “true” catheters,
appropriate use of butterfly catheters, and adequate patient restraint coupled with monitoring during administration
will prevent extravasations and the devastating consequences thereof. Management of extravasations in human and
feline medicine is anecdotal and extremely controversial. Despite this controversy, guidelines have been established
for clinical use.
As expected, accurate and secure “first stick” catheter placement is absolutely essential when administering
drugs that can cause tissue damage if extravasated perivascularly. Generally, only small-gauge (22 to 23 ga)
indwelling intravenous (IV) catheters should be used when treatment volumes exceed 1 ml; 23 to 25 ga butterfly
needles can be used for administering small volumes of drugs (e.g., vincristine). Everyone involved in patient care
should note when and where blood samples are taken by venipuncture and where catheters have been placed
previously. This prevents administration of chemotherapeutic agents through veins that may leak because of
previous procedures. Drawing blood samples from peripheral veins should be avoided if at all possible to preserve
these veins for catheter access. Only catheters that have been placed very recently should be used for
administration of chemotherapeutic agents.
Extreme care should be taken when administering drugs to all cats; however, veins in some patients (e.g.,
extremely debilitated animals, diabetics, some elderly cats, patients that have been receiving weekly or biweekly
therapy for a significant period) are even more fragile. Catheters should be checked for patency by injecting a large
volume of saline (e.g., 12 to 15 ml) before and after drug administration. In addition, it is mandatory that catheters be
Track A
visually monitored closely and checked for patency throughout drug infusion.
Diagnosis
Usually, there is no doubt whether an extravasation has occurred. Some agents are very caustic when given
perivascularly, and cats may vocalize or physically react to pain at the injection site. Treatment for extravasation
must begin immediately. Evidence of tissue necrosis generally does not appear for 1 to 10 days after extravasation
and may progress for 3 to 4 weeks. The lesions occur early with vinca alkaloids and late with anthracycline antibiotics
(e.g., doxorubicin). Lesions may begin as mild erythema and progress to open, draining wounds that will not heal
without extensive debridement and plastic surgery; such treatment should not be initiated until all damage is evident
(i.e., weeks to months after the perivascular slough begins)
1–4
Treatment
Everyone involved with the administration of chemotherapeutic agents should be aware of procedures for
treating extravasation. Such procedures (i.e., immediately aspirating as much drug as possible from the injection site;
.instilling saline and applying hot compresses if vincristine or vinblastine was administered perivascularly; placing ice
packs around the area in question if doxorubicin was administered perivascularly) should be posted in a common
area, and all needed materials should be readily available and accessible. Because of their extensive use in feline
practice, doxorubicin and the vinca alkaloids are the most common causes of perivascular sloughing. Unfortunately,
no method effectively eliminates tissue necrosis. For example, sodium bicarbonate, corticosteroids, dimethyl
sulfoxide (DMSO), α-tocopherol, N-acetylcysteine, glutathione, lidocaine, diphenhydramine, cimetidine, propranolol,
4
and isoproterenol are not effective for treating doxorubicin extravasations.
Once tissue damage is identified, an Elizabethan collar and bandages with nonstick pads are essential to
allow the area to heal without self-trauma. Bandages should be changed daily as long as the area is draining or has
253
the potential for infection. If a bacterial infection is noted, culture and sensitivity testing and appropriate administration
of antimicrobials are essential. Frequent cleansing and debridement may be necessary. In some cases,
reconstructive surgical repair techniques are needed. In the event of doxorubicin extravasations, limb amputation
may become necessary
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abnormalities. J Feline Med Surg. 15(3): 189-199, 2013.
25. 11.Leifer CE, Peterson ME, Matus RE, Patnaik AK: Hypoglycemia associated with nonislet cell tumors in 13
dogs. JAVMA 186:53–62, 1985.
26. Giger U, Gorman NT: Acute complications of cancer and cancer therapy, in Gorman NT (ed): Oncology. New
York, Churchill Livingstone, 1986, pp 147–168.
27. Sheafor SE, Gamblin RM, Couto CG: Hypercalcemia in two cats with multiple myeloma. JAAHA 32:503–508,
1996.
28. McClain HM, Barsanti JA, Bartges JW: Hypercalcemia and calcium oxalate urolithiasis in cats: A report of
five cases. JAAHA 35:297–301, 1999.
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29. Marquez GA, Klausner JS, Osborne CA: Calcium oxalate urolithiasis in a cat with a functional parathyroid
adenocarcinoma. JAVMA 206:817–819, 1995.
30. Mahoney CP, Cassady C, Weinberger E, et al: Humoral hypercalcemia due to an occult renal adenoma.
Pediatr Nephrol 11:339–342, 1997.
31. Anderson TE, Legendre AM, McEntee MM: Probable hypercalcemia of malignancy in a cat with
bronchogenic adenocarcinoma. JAAHA 36:52–55, 2000.
32. Ogilvie GK, Curtis C, Richardson RC, et al: Acute short term toxicity associated with the administration of
doxorubicin to dogs with malignant tumors. JAVMA 195:1584–1587, 1989.
33. Ogilvie GK, Walters LM, Powers BE, et al: Organ toxicity of NBT Taxol in the rat and dog: A preclinical study.
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34. Ogilvie GK, Cockburn CA, Tranquilli WJ, Reschke RW: Hypotension and cutaneous reactions associated
with etoposide administration in the dog. Am J Vet Res 49:1367–1370, 1988.
35. Teske E, Rutteman GR, Heerde P van, Misdorp W: Polyethylene glycol-L-asparaginase versus native L-
asparaginase in canine non-Hodgkin’s lymphoma. Eur J Cancer 26:891–895, 1990.
36. Nesbit M, Chard R, Evans A, et al: Evaluation of intramuscular versus intravenous administration of L-
asparaginase in childhood leukemia. Am J Pediatr Hematol Oncol 1:9–13, 1979.
37. Degen MA: Acute hypersensitivity reactions, in Kirk RW (ed): Current Veterinary Therapy X. Philadelphia,
WB Saunders, 1989, pp 537–542.
38. Fabry U, Korholz D, Jurgens H, et al: Anaphylaxis to L-asparaginase during treatment for acute
lymphoblastic leukemia in children. Evidence of a complement-mediated mechanism. Pediatr Res 19:400–
408, 1985.
39. Ogilvie GK, Atwater SW, Ciekot PA, et al: Prevalence of anaphylaxis associated with the intramuscular
administration of L-asparaginase to 81 dogs with cancer: 1989–1991. JAAHA 3662–3665, 1994.
40. Ogilvie GK: Chemotherapy induced anaphylaxis, in Wingfield WE (ed): Veterinary Emergency Medicine
Secrets. Philadelphia, Hanley and Belfus, 2001, pp 257–258.
41. Ogilvie GK: Extravasation of chemotherapeutic agents, in Wingfield WE (ed): Veterinary Emergency
43. Hubbard SM, Jenkins JF: Chemotherapy administration: Practical guidelines, in Chabner BA, Collins JM
(eds): Cancer Chemotherapy: Principals and Practice. Philadelphia, JB Lippincott, 1990, pp 449–464.
44. Hubbard S, Duffy P, Seipp C: Administration of cancer treatments: Practical guide for physicians and nurses,
in DeVita VT Jr, Hellman S, Rosenberg S (eds): Cancer: Principles and Practice of Oncology, ed 3.
NOTES:
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NOTES:
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256
The Secret Weapon: Polyunsaturated Fatty Acids and Cancer - Advances for 2015
Introduction
Nutritional therapy is a key component for the prevention and treatment of cognitive dysfunction,
osteoarthritis, heart and vascular disease, cancer and cancer cachexia in many species and there is growing
information to affirm that this is likely true in cats. Indeed, recent research has shown that cats are genetically quite
1
unique. Investigators identified positively selected genes enriched for genes involved in lipid metabolism that
underpin adaptations to a hypercarnivorous diet. Hence their unique nutritional requirements. While not related to the
subject of this document, it is interesting that they found positive selection signals within genes underlying sensory
processes, especially those affecting vision and hearing in the carnivore lineage. We observed an evolutionary
tradeoff between functional olfactory and vomeronasal receptor gene repertoires in the cat with an expansion of
the feline chemosensory system for detecting pheromones at the expense of odorant detection. Hence, the reason
why we are servents to the cat, and companions to the d-g.
Our feline aficionado clients often demand far more from us as practitioners and hence the reason for this
document. Nutrients are potent substances that not only provide nutrients, but they can and do actually treat medical
disorders, including cancer. Cats are unique and they have unusual metabolic pathways that demand that the feline
practitioner understand these issues and respond with feline specific nutritional therapy. Nutritional therapy and
supplements are in a non-regulated area: some take liberty in overstating their benefits. Thus, nutritional therapy and
supplements, like all other treatments should be placed into those that work, those that are being evaluated, and
thoes that do not work. The later should be excluded from use. Specific nutrients supplements can be used as
powerful tools to reduce toxicity associated with chemotherapy, radiation therapy, and is important to enhance
healing subsequent to surgery. There is little doubt in the cat that nutritional intervention must begin early and must
be followed through aggressively to gain maximum benefit…..long before the patient exhibits evidence of weight loss,
debilitation, or anorexia begin which can in turn enhance response to therapy and improve quality of life.
Cancer and Its Effects on the Body: Targets for Nutritional Intervention
Cancer causes dramatic changes in metabolism resulting in elevated lactate concentrations, especially when
the patient is given simple carbohydrates orally or intravenously, alterations and protein metabolism resulting in
protein wasting to the benefit of the host, and alterations in lipid metabolism. In fact, fat loss accounts for the majority
of weight loss occurring in cancer cachexia. Therefore, it is not surprising that human beings and animals with
1-10
cancer have dramatic abnormalities in lipid metabolism. The decreased lipogenesis and increased lipolysis
observed in humans and rodents with cancer cachexia result in increased levels of free fatty acids, very low density
lipoproteins, triglycerides, plasma lipoproteins, and hormone dependent lipoprotein lipase activity, while levels of
Track A
1-10 1-2
endothelial derived lipoprotein lipase decrease. Lipid profiles in dogs and cats with a lymphoma were studied.
It was determined that many of the alterations seen in other species with cancer were also present in companion
animals. These abnormalities did not normalize when clinical remission is obtained. The clinical significance of these
abnormal lipid profiles in companion animals with lymphoma is not known, however, abnormalities in lipid metabolism
have been linked to a number of clinical problems including immunosuppression.
The clinical impact of the abnormalities in lipid metabolism may be lessened with dietary therapy. In contrast
to carbohydrates and proteins, some tumor cells have difficulty utilizing lipid as a fuel source while host tissues
1-3
continue to oxidize lipids for energy. This has led to the hypothesis that diets relatively high in fat may be of benefit
to the animal with cancer when compared to a diet high in simple carbohydrates. This recommendation is doubly
important for cats as dietary or intravenous glucose results in prolonged glucose levels with a greater area under the
curve due to the lack of glucose kinase in this species. Similarly, insulin resistance occurs to a much greater extent in
cats than other companion animals, especially when the patient has any degree of obesity. Additionally, this
approach is even more magnified when realizing that obest cats that undergo any degree of anorexia begin the
process of developing hapatic lipidosis. When speaking of obesity, it is important to realize that diets including
prebiotics, green tea extract, or increased concentrations of protein have been shown to modify the expression of
2
several genes related to glucose and lipid metabolism in adipose tissues. These nutrients uncouple protein-2,
carnitine palmitoyltransferase-1, PPARα, lipoprotein lipase, and glucose transporter 4 and skeletal muscle. In
general, the outcomes derived from these studies demonstrated that d-gs and cats share similar adipokines and
hormones to other species, and they are affected in a similar fashion during obesity. Thus, some of what happens in
one species likely impacts the other.
Differences in glucose and lipid metabolism related gene expression in the cat confirms that this species has
a lower metabolic rate in various tissues which may be attributed to overall lower insulin signaling gene expression
and a lack of physical activity as compared to “the other” companion animal, the d-g. Therefore, a combination of
genetic and environmental factors appears to make cats, especially those with cancer and other diseases more
257
prone to suffer from insulin resistance and type 2 diabetes mellatus. Further research may reveal that the type of fat,
rather than the amount, may be of greater importance. This has resulted in one product, Impact that has been
reported to benefit mean nitrogen intake, nitrogen balance, in vitro lymphocyte mitogenesis, time for wound healing,
1-3
the prevalence of wound complications, and the duration of hospitalization. Studies of polyunsaturated fatty acids
(PUFA's) of the n-3 series, especially eicosapentaenoic (EPA) and docosahexaenoic acid (DHA), indicate that these
fatty acids may prevent the development of carcinogen-induced tumors, the growth of solid tumors, as well as the
occurrence of cachexia and metastatic disease in experimental tumor models. Fatty acids of the n-3 series have
been shown to normalize elevated blood lactic acid and insulin levels in non-malignant conditions. In contrast,
PUFA's of the n-6 series appear to enhance tumor development and metastases. These data, along with the
epidemiological findings of an inverse relationship between dietary n-3 fatty acid intake and incidence of some
cancer, cognitive dysfunction, degenerative joint disease and asthma is the basis of research to evaluate the
potential benefit of n-3 fatty acids in the prevention of cancer cachexia and therapy of malignancy in cancer patients.
Nutrition and Cancer for the Clinician: The Evidence

A study was recently completed in “the other” companion animal, the d-g with lymphoma14 and there is a
modicum of evidence of similar results in the cat (the real species!). A double blind, randomized study was reported
to evaluate the hypothesis that polyunsaturated n-3 fatty acids and arginine can improve metabolic parameters,
decrease chemical indices of inflammation, enhance quality of life, and extend disease-free interval and survival time
in d-gs treated for lymphoma. The diet was Feline Prescription Diet kd plus fish oil vs a high carbohydrate diet. In that
study, this companion animal was fed the experimental diet had significantly higher serum levels of polyunsaturated
n-3 fatty acids docosahexaenoic acid (C22:6) and eicosapentaenoic acid (C20:5) as well as arginine when compared
to controls. Both diets were formulated to be relatively low in simple carbohydrates, with moderate amounts of highly
bioavailable proteins. This formulation is designed to enhance the effect of n-3 fatty acids. Higher serum levels of
these n-3 fatty acids were associated with lesser plasma lactic acid responses to intravenous glucose and diet
tolerance testing. Increasing C22:6 levels was significantly associated with longer disease free interval and survival
time for dogs with stage III lymphoma fed the experimental diet.
Another study was recently completed that was designed to determine the effect of a diet supplemented with
n-3 fatty acids and arginine on irradiated skin and oral mucosa, carbohydrate metabolism and quality of life in a
group of d-gs and cats with nasal tumors. This study showed that fatty acids of the n-3 series normalize elevated
blood lactic acid. In a dose dependent manner, n-3 fatty acids result in decreased histologic evidence of radiation
damage to skin and mucosa and improve performance scores in those with malignant nasal tumors. This would
obviously be of great benefit to the cancer patient receiving radiation therapy and the metabolism of lipids by cats
may in part explain why this species is so refractory to radiation induced adverse effects. These two studies confirm
that diets supplemented with polyunsaturated n-3 fatty acids are of benefit for the cancer patient.
The bottom line is that n-3 fatty acids in moderate amounts appear to benefit the cancer patient. More
specifically, a diet relatively high in n-3 fatty acids and relatively low in simple carbohydrates has been shown not
only to improve alterations in metabolism associated with cancer, but also improve response to chemotherapy and
decrease the adverse effects associated with radiation therapy.
Track A
One might wonder about the toxicity of using high dosages of n-3 fatty acids and the cancer patient. Dr. John
Bauer published an article in JAVMA outlining the threats of n-3 fatty acid supplementation. Our research since the
mid 1980’s has shown that the use of relatively high dosages of n-3 fatty acids does not cause abnormal
prolongation of platelet aggregation or delayed wound healing, especially in the cat. In another study, Dr. Bauer and
colleagues asked the question if a fish oil or vegetable oil supplemented diet would negatively impact cats, especially
3
be depleting arachidonic acid. They showed that oversupplementation of some commercial diets with vegetable oils
causes arachidonic acid depletion in cats due to dietary dilution. Findings are consistent with the current
recommendations for at least 0.2 g arachidonic acid/kgdiet and that fish oil supplements provide both preformed long
chain n-3 polyunsaturated fatty acids and arachidonic acid. This is great since arachidonic acid depletion is
associated with weight loss and anorexia, among other issues.
We recently completed a double blind, randomized study to test the hypothesis that an n-3 supplemented
diet would not cause significant alternations in hemograms or select biochemical profile parameters when compared
to a placebo diet not supplemented with polyunsaturated n-3 fatty acids in the dog. We have completed similar
studies in the dog (publications pending). In the study involving the inferior species, 34 d-gs with lymphoma and 8
dogs with hemangiosarcoma were randomized to receive one of two diets supplemented with menhaden fish oil and
arginine (experimental diet) or an otherwise identical diet supplemented with soybean oil (control diet). Diets were
fed for 18 weeks before and after remission were attained with up to 5 dosages of doxorubicin in the case of d-gs
with lymphoma, and after surgery and for 18 weeks during and after doxorubicin in the case of the d-gs with
hemangoisarcoma. Parameters examined included hemograms and select biochemical parameters (glucose, BUN,
creatinine, phosphorus, calcium, total protein, albumin globulin, A/G ratio, cholesterol, t-bilirubin, sodium, potassium,
chloride, bicarbonate, anion gap). There were no significant differences in weights or kcal consumption between
groups. The only significant difference occurred for serum cholesterol. D-g s that received the n-3 supplemented diet
had significantly lower serum cholesterol concentrations than d-g s fed the control diet. Dietary polyunsaturated fatty
258
acids have been shown to reduce serum cholesterol concentrations in many species, and may be important in those
disease conditions associated with increased serum cholesterol. Changes in serum cholesterol may reflect changes
in cell membrane lipid content that can affect tumor cell metastasis or immune cell responsiveness to malignant cells.
A separate study performed by Duncan LaSalles evaluated a diet high in n-3 fatty acids from fish and Green Lipped
11
Mussels revealed that this approach was similarly safe. He and his colleagues also showed that a diet high in EPA
and DHA and supplemented with green-lipped mussel extract and glucosamine/chondroitin sulfate improved
objective measures of mobility in the cat. Comfort and quality of life is always a feline practitioner’s dream.
PUFA’s, Cancer and MMP’s

It appears that fatty acids may regulate matrix metalloproteinases in the d-g and the magical cat (even those
who are not magical). In order to understand this further, a review of matrix metalloproteinases is in order. Matrix
metalloproteinases (MMPs) are a family of zinc dependant enzymes that are produced by multiple tissues throughout
the body, and are involved in the degradation of extracellular matrix and basement membrane components. There
3
are currently at least seventeen unique MMPs characterized that can be sub-divided into groups according to
substrate preferences: collagenases, stromelysins, gelatinases, and membrane bound enzymes. Matrix
metalloproteinases are active during normal tissue remodeling processes such as embryogenesis and wound
healing, as well as pathologic processes such as rheumatoid arthritis, degenerative joint disease, cancer metastasis
and invasion, and angiogenesis. MMP-2 and MMP-9 have been associated with malignant tumor progression and
metastasis. For tumor cells to become metastatic, they must cross at least two basement membranes to enter and
exit the vasculature at the primary and metastatic sites. MMP’s 2 and 9 are thought to be important in this process,
as well as facilitating tumor invasion into surrounding normal tissues. These enzymes can be present in a
progelatinase and an active gelatinase form. In several human tumor types, levels of MMP’s 2 and 9 have been
found to be increased when compared to normal or benign tissue. These include breast, prostate, colon, gastric, and
bladder cancers. Studies done with rodent colon, lung and breast tumor models show that the inhibition of MMPs can
lead to a more favorable outcome. The same thing has been shown in cats with a wide variety of malignancies.
This knowledge led us to hypothesis that the presence of MMP 2 and 9 in the tumor, serum and plasma
correlated with the presence of canine and feline malignancies and these levels correlate with histologic grade of
tumor. Tumor, plasma, serum and stromal tissue were harvested from d-gs and cats with various histologically
confirmed and graded malignancies prior to therapy and banked at -70C and subsequently analyzed by gelatin
zymography to detect MMP 2 and 9 activity compared to commercially available MMP 2 and 9 human standards. D-
gs and cats with measurable levels of active form MMP 9 were over 3 times more likely to come out of remission
than subjects who had zero levels. D-gs and cats with the active form of MMPs present were, in general, significantly
more likely to come out of remission by 90 days than subjects with no active form of MMPs present. This was
especially true when active form of MMPs were present in d-gs with lymphoma. In general, d-gs and cats with stage
IV lymphoma had the highest levels of MMP's and had the poorest outcome compared to those with stage III
disease. These data allow some to draw the conclusion that MMP inhibitors may indeed be of value in treating cats
with cancer.
In order to determine the ability of n-3 fatty acids to inhibit matrix metalloproteinases, we performed a blind,
Track A
randomized study designed to evaluate the hypothesis that short-term supplementation with polyunsaturated n-3
fatty acids can decrease serum, plasma and tumor concentrations of MMP 2 and 9, VEGF, and lactate and and
enhance concentrations of tissue inhibitors of MMP’s (TIMP-2). Cats rarely get osteosarcoma, therefore a study was
done in the lesser species for expediency. Nineteen d-gs with osteosarcoma (9) and soft tissue sarcomas (10) were
randomized to receive one of two diets identical in all ways except the experimental diet was supplemented with
menhaden fish oil while the otherwise control diet was supplemented with soybean oil. Diets were fed prior to biopsy
and for 2-3 weeks until the tumor was biopsied again. D-gs fed the experimental diet higher median serum levels of
the n-3 fatty acids docosahexaenoic acid (C22:6) and eicosapentaenoic acid (C20:5) and lower concentrations of the
n-6 fatty acids, 18:2 and 20:4 when compared to controls. D-gs fed the control diet had higher glucose
concentrations and lower plasma concentrations of pro and active MMP-2 and lactate. In addition, the concentration
of pro MMP 9 and active MMP 2 decreased in the experimental group and increased in the control group.
Concentrations of TIMP-2 and VEGF increased in both groups.
“Other” Nutrients and Cancer

Zinc deficiency is a common finding in human cancer patients, especially those with head and neck cancer.
Cell-mediated immunity and natural killer (NK) cell activity are sub-optimal in zinc-deficient patients. Zinc-deficient
cancer patients experience increased treatment morbidity, treatment delays, and unplanned hospitalizations.
Chromium deficiency is a causative factor in decreased glucose tolerance, a recognized paraneoplastic syndrome. It
can lead to hyperinsulinemia and hyperlactatemia, both of which have been observed in human and animal cancer
patients. Iron metabolism is altered in the presence of inflammation or neoplasia. Most commonly, metabolism is
shifted toward sequestration, which is manifested by a decrease in serum iron concentration and total iron binding
capacity, and an increase in serum ferritin concentration. Iron sequestration may be the mechanism for anemia of
chronic disease because of difficulty using iron in a storage pool.
259
67
Iron transferrin and ferritin have been linked to cancer risk and cancer cell growth. Lung cancer, colon,
bladder and esophageal cancer in people has been highly correlated with increased serum iron and increased
67
transferrin saturation. This may be because many tumor cells require iron for growth.
One key question comes up often: should antioxidants be used to support the cancer patient. One answer to
this question come from the knowledge that polyunsaturated fatty acids (PUFA) increase the sensitivity of breast
cancer cells to cytotoxic drugs that generate an oxidative stress and found this effect to be abolished by vitamin E,
suggesting the involvement of lipoperoxides in cell death. The most efficient PUFA was docosahexaenoic acid
(DHA). Since an enrichment with n-3 PUFA of the diet of breast cancer patients has been reported to lead to an
increased level of DHA in breast adipose tissue (Bagga et al, J Natl Cancer Inst 1997, 89: 1123), a dietary
intervention should provide an effective means to increase DHA availability in tumor tissues and thereby should
increase drug efficacy on tumors (Shao et al, Nutr Cancer, 1997, 28:63). This circumstantial evidence now requires
direct demonstration through a clinical trial.
References
1. Montague MJ, Li G, Gandolfi B, et al: Comparative analysis of the domestic cat genome reveals genetic
signatures underlyingfeline biology and domestication. Proc Natl Acad Sci U S A. 111(48):17230-17235,
2014.
2. de Godoy MR, Swanson KS. Companion Animals Symposium: nutrigenomics: using gene expression and
molecular biology data to understand pet obesity. J Anim Sci. 91(6):2949-2964, 2013.
3. Mori A, Lee P, Takemitsu H et al: Comparison of insulin signaling gene expression in insulin sensitive tissues
between cats and dogs. Vet Res Commun. 33(3):211-226, 2009.
4. Vail DM, Ogilvie GK, Wheeler SL, Fettman MJ t al: Alterations in carbohydrate metabolism in canine lymphoma.
J Vet Intern Med 4:8-11, 1990.
5. Vail DM, Ogilvie GK, Fettman MJ, Wheeler SL: Exacerbation of hyperlactatemia by infusion of lactated Ringer's
solution in dogs with lymphoma. J Vet Intern Med 4:228-232, 1990.
6. Ogilvie GK, Vail DM, Wheeler SJ. Effect of chemotherapy and remission on carbohydrate metabolism in dogs
with lymphoma. Cancer 69:233-238, 1992.
7. Ogilvie GK, Walters LM, Salman MD, et al. Alterations in select aspects of carbohydrate, lipid and amino acid
metabolism in dogs with non-hematopoietic malignancies, Am J Vet Res, 8:62-66, 1994.
8. Ogilvie GK, Ford RD, Vail DM et al: Alterations in lipoprotein profiles in dogs with lymphoma. J Vet Intern Med.
1994;8:62-66.
9. OgilvieGK, Fettman MJ, Mallinckrodt CH, Walton JA, Hansen RA, Davenport DJ, Gross KL, Richardson KL,
Rogers Q, Hand MS. Effect of fish oil and arginine on remission and survival time in dogs with lymphoma.
Cancer, 2015.
10. Ogilvie GK, Salman MD, Fettman MJ et al. Effect of anesthesia and surgery on energy expenditure
determined by indirect calorimetry in dogs with malignant and non-malignant condition. Am J Vet Res,
1996;57:1321-326.
11. Lascelles BD, DePuy V, Thomson A, et al: Evaluation of a therapeutic diet for feline degenerative joint
Track A
disease. J Vet Intern Med. 24(3):487-495; 2010.

12. Ogilvie GK, Walters LM, Fettman MJ, et al. Energy expenditure in dogs with lymphoma fed two specialized
diets. Cancer 1993;71:3146-3152
13. Angell RJ, McClure MK, Bigley KE, et al: Fish oil supplementation maintains adequate plasma arachidonate
in cats, but similar amounts of vegetable oils lead to dietary arachidonate deficiency from nutrient dilution.
Nutr Res. 32(5):381-389, 2012.
14. Ogilvie GK, Fettman MJ, Mallinckrodt CH et al. Effect of fish oil, arginine, and doxorubicin chemotherapy on
remission and survival time for dogs with lymphoma: a double-blind, randomized placebo-controlled study.
Cancer 2000 15;88(8):1916-1928.
NOTES:
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Chemotherapy Drugs
Introduction
Conventional chemotherapy drugs have been used in cats for decades, and the development of new anti-
cancer drugs has increased the medical options for cats with cancer. In this talk the evidence for why we give
chemotherapy the way that we do in cats will be presented, and areas of missing evidence will be pointed out as
well. Most of the chemotherapy drugs discussed in this session are used to treat lymphoma and other cancers in
cats, so their efficacy will be discussed in the sessions on feline lymphoma and those other cancers. The main
purpose of this session is to describe the administration and toxicity of select anti-cancer drugs in cats. The
information presented here is not intended to be and should not be used as a replacement for consultation with an
oncologist.
Receptor Tyrosine Kinase Inhibitors (RTKIs)

The following information provides a detailed review of the current literature describing the use of RTKIs in
cats. Interestingly, only imatinib seems to be effective for feline mast cell tumors. Injection-site sarcomas are a
potential target for these drugs in feline patients due to their overexpression of platelet-derived growth factor
receptor. A summary of pertinent information regarding using these drugs in cats is provided in Table 1.
TM
Imatinib mesylate (Gleevec )
Imatinib is one of the earlier protein tyrosine kinase inhibitors. It is selective for platelet-derived growth factor
receptor, c-kit receptor, and Bcr-Abl receptor. A dose escalation study documented no or low grade toxicity in 8 of 9
1
cats treated. The last cat developed significant azotemia, leukocytosis, and hepatic enzyme elevations after
receiving a low dose of imatinib for 2 weeks. The four cats in that study with vaccine-associated sarcomas
experienced stable disease for an average of 2 months, which could have been due to imatinib or indolent clinical
behavior of their tumors. Pharmacokinetic analysis was not performed in that study, so the oral bioavailability of
imatinib in cats remains unknown. In addition, most cats were treated for a relatively short period of time (less than 2
months) so clinical implications of long-term use of the drug is also unknown. One case report describes the use of
2
imatinib in a cat with a mast cell tumor with an internal tandem duplication mutation in exon 8 of c-kit. This cat had
multiple cutaneous tumors as well as peripheral blood mastocytosis and experienced a complete response after 5
weeks of daily oral treatment with imatinib. Follow up after 5 weeks was not provided in the report so the duration of
the response remains unknown. The dose used was 10 mg/kg/day, which is the second highest dose reported in the
1,2
dose escalation study.
After the positive result of the case report describing the use of imatinib mesylate in cat with a mast cell
tumor, that same author published a study describing the prevalence of c-kit mutations in feline mast cell tumors and
3
the clinical response to imatinib in 10 cats. A total of 62 feline mast cell tumors were analyzed for c-kit mutations in
various locations, and 67.7% of the samples were found to have a mutation, with mutations in exon 8 and 9 being the
most common. Of the 10 cats, 8 had a mutation in the c-kit gene, and 7 of those 8 cats had an objective response to
imatinib.
In addition to showing promise for treating feline mast cell tumors, an in vitro study suggests that imatinib
4
may be effective for feline injection site sarcomas. These tumors have increased expression of platelet-derived
growth factor, and the study showed that imatinib inactivated platelet-derived growth factor receptor and decreased
growth of feline injection site sarcoma cell lines. In addition, imatinib increased the sensitivity of the cells to
chemotherapy and significantly decreased the growth of feline injection site sarcomas that were implanted into nude
mice. Unfortunately, the lack of pharmacokinetic data regarding imatinib in cats means that it is unknown if the
concentrations used in the in vitro study are achievable in clinical feline patients.
The development of veterinary-specific RTKIs and the cost of imatinib has stalled further evaluation of this
drug in cats, and given the high rate of c-kit mutations in feline mast cell tumors, it is reasonable to expect that feline
mast cell tumors would also respond to toceranib phosphate and masitinib.
Track B
TM
Masitinib mesylate (Kinavet )
Masitinib is FDA-licensed for use in canine mast cell tumors. In addition to inhibiting the KIT receptor, it also
inhibits platelet derived growth factor receptor. One study in healthy cats involved administering approximately 12.5
5
mg/kg orally every day or every other day for 4 weeks. The treatment was well-tolerated in both groups, though 2
cats in the daily dosing group were switched to the every other day dosing group due to neutropenia. Two cats in the
daily dosing group developed proteinuria during the last week of treatment that resolved within 2 weeks after
discontinuing the drug. Cats had significant increases in creatinine and significant decreases in albumin during the
course of the study, but the values did not exceed the upper or lower limits of the reference ranges.
261
Pharmacokinetic analysis of masitinib mesylate in cats has shown that the oral bioavailability of the drug is
6
60%, with a shorter half-life (3-5 hours) compared to dogs (10 to 20 hours). Given the results of the safety study it
seems that every other day dosing is preferable from a toxicity perspective, but that may result in lower efficacy given
the pharmacokinetic information.
Two studies have evaluated the potential therapeutic effect of masitinib in feline injection site sarcoma cell
7,8
lines. The first study found that masitinib decreased cell viability and inhibited the activity of platelet-derived growth
factor receptor; however, the effective drug concentrations in vitro are likely to be poorly tolerated in feline patients
5,6,7
based on the previous pharmacokinetic and safety studies. That being said, it is possible that masitinib could be
effective at lower doses than those suggested by the in vitro study. When the potential for masitinib to sensitize
feline injection-site sarcoma cell lines to radiation therapy was evaluated, no difference in cell viability was noted
when radiation alone and radiation combined with masitinib were compared, indicating that masitinib may not be a
8
viable radiosensitizing agent for this tumor.
TM
Toceranib phosphate (Palladia )
Toceranib is also FDA-licensed for the treatment of mast cell tumors in dogs. Compared to imatinib and
masitinib, the least amount of information has been published regarding the use of toceranib in cats. Limited
information regarding dose escalation and pharmacokinetics of toceranib phosphate in cats is available. That study
described dose escalation up to 6.5 mg/kg per day given orally to healthy cats. Decreased appetite, weight loss,
9
vomiting, and diarrhea occurred at that dose. Another abstract retrospectively describing the use of toceranib for a
variety of tumor types in 29 cats at a median dosage of 3 mg/kg orally three to four times a week found that
10
gastrointestinal toxicities were most common, with 5 cats having anorexia and 3 having vomiting. Of the 8 cats with
squamous cell carcinoma included in the study, 1 had a complete response, 4 had stable disease, and 3 had
progressive disease. Of the 7 cats with injection-site sarcomas, 3 had a partial response, 2 had stable disease, and
2 had progressive disease. Cats with mast cell tumors, carcinomas, multiple myeloma, and other sarcomas were
included in the study, and response information was not provided for those cats.
Table 1. Summary of reported doses, side effects, and potential therapeutic indications for receptor tyrosine kinase
inhibitors (RTKIs) in cats.*One cat developed azotemia and elevated hepatic enzymes which the authors stated
could have been unrelated to imatinib mesylate.
Drug Reported Dose Side Effects Tumor Type References

Imatinib mesylate 10 mg/kg/day PO Lethargy, vomiting* Mast cell tumor, 1-4
Injection-site sarcomas
Masitinib mesylate 12.5 mg/kg daily or Neutropenia, Injection-site sarcomas 5-8
every other day PO proteinuria
Toceranib 3 mg/kg 3-4 times Anorexia, vomiting, Squamous cell 9-10
phosphate per week PO weight loss, diarrhea carcinoma, injection-site
sarcoma
Conventional Chemotherapy Drugs

The following information provides a detailed review of the current literature describing the use of select
chemotherapy drugs in cats. The drugs with the most evidence for dosing and information regarding potential toxicity
are included. Efficacy of these drugs for particular feline cancers will be discussed in the sessions focused on those
cancers. A summary of pertinent information regarding using these drugs in cats is provided in Table 2.
Doxorubicin
Doxorubicin is an anthracyline antibiotic with several mechanisms of action. It is most commonly used in
cats for lymphoma, mammary carcinoma, and soft tissue sarcomas.
11,12
Two studies specifically evaluate the toxicity of doxorubicin in healthy cats. Forty-six doses total doses
2
were administered to 6 healthy cats. The dose used was 30 mg/m every 21 days, and 10 treatments were planned
per cat. The most common side effects included decreased appetite, vomiting, neutropenia (14 events, 5 of which
were accompanied by fever), and diarrhea. By the end of the study, mean weight loss compared to baseline among
the cats was 27.3%. Three cats developed clinically detectable renal dysfuction, and all cats had renal abnormalities
Track B
noted at necropsy. It is interesting that although no clinical signs of cardiac dysfunction were noted, echocardiogram
and histopathological examination revealed changes consistent with doxorubicin toxicity. The authors noted that the
timing of the decreased appetite and vomiting was sporadic. Anecdotally, this author has found weight loss and
decreased appetite to be the most common toxicities in cats receiving doxorubicin even at lower doses (1 mg/kg),
and the decreased appetite can be prolonged up to 2 or 3 weeks after a dose. Although severe tissue damage
following extravasation of doxorubicin is well-recognized in dogs, only one case report describes the outcome of
13
doxorubicin extravasation in a cat. In fact, this case report was the first report of using dexrazoxane (an iron
chelator and free radical scavenger) in a domestic animal after doxorubicin extravasation. The cat in the case report
262
experienced a witnessed extravasation, and following dexrazoxane administration developed fibrous tissue and
eventually a callous at the site, but no open wound or detectable patient discomfort occurred.
A later study compared different dosing schemes for doxorubicin in cats and found no significant difference
14 2
in most toxicities between the groups. Cats received either 1 mg/kg, which is approximately 20 mg/m in most cats,
2
or 25 mg/m with subcutaneous fluids. The drug was administered over 5 to 10 minutes. Cats that received the
higher dose had a significantly higher incidence of neutropenia and significantly lower post-treatment neutrophil
counts. Otherwise no differences were noted in toxicities between the groups. As expected, gastrointestinal
toxicities were most common. Ten of the sixty cats included developed azotemia, and this toxicity was also not
different between the groups. The authors concluded that since toxicities that are more likely to affect quality of life
(vomiting, anorexia, renal dysfunction) were not different between the groups, it is reasonable to dose cats at
25mg/m2 in order to improve efficacy of the drug. In this retrospective study many cats received doxorubicin as part
of a combination chemotherapy protocol, though the likelihood of receiving doxorubicin alone or as part of
combination therapy was not different between the groups. The authors did not comment on the use of supportive
care medications such as anti-emetics or appetite stimulants in the study, so it is unknown if their use (or lack
thereof) was different between the two groups. The standard cat doxorubicin dose used at this author’s institution is
1mg/kg every 21 days.
The rate of infusion of doxorubicin affects the pharmacokinetics as well, with a slower infusion rate resulting
15
in a greater area under the curve and longer distribution phase when compared to a faster infusion rate. Cats in
2
that study were dosed at 25 mg/m or 1 mg/kg, and infusions were given over 10, 15, and 20 minutes. It is unclear
how much this alteration of pharmacokinetics affects drug efficacy, and that potential benefit must be weighed
against the practical act of administering doxorubicin to cats and the potential need for and risk of sedation to allow a
longer infusion to be safely administered.
2
Overall, there is clinical and pharmacokinetic evidence to support doses of 1 mg/kg or 25 mg/m every 3
weeks in cats with doxorubicin. Caution should be used in cats with pre-existing renal and hepatic disease, given the
potential for renal toxicity and the fact that doxorubicin is primarily metabolized by the hepatobiliary system.
Platinum Agents
Cisplatin is associated with the development of fatal pulmonary toxicity in cats following intravenous dosing,
16
so Carboplatin (which has not been associated with that toxicity) will be the focus of this section. The primary
mechanism of action of carboplatin is DNA binding. Its use in cats is primarily for carcinomas, including mammary
carcinoma, anal sac adenocarcinoma, colonic adenocarcinoma, and squamous cell carcinoma, though it has been
used to treat soft tissue sarcomas as well.
Myelosuppression with resultant neutropenia and thrombocytopenia is the most commonly reported toxicity
17, 18
in cats treated with carboplatin, while gastrointestinal toxicity is infrequently noted. When healthy cats were
2 2 2
treated with carboplatin at doses of 150 mg/m , 200 mg/m , and 250 mg/m , the dose-limiting toxicity was
17
neutropenia, and thrombocytopenia was noted as well. Nadirs were reported to occur between days 14 and 17, and
neutrophil recovery took up to 11 days. No pulmonary or gastrointestinal toxicity was noted. The authors
2
recommended a dose of 200 mg/m every 4 weeks. A Phase I study of carboplatin in cats with a variety of
spontaneous tumors again found that (asymptomatic) neutropenia was the dose-limiting toxicity, and a dose of 240
2 18
mg/m given every 3 weeks was recommended.
Carboplatin is renally excreted, and the correlation between glomerular filtration rate, carboplatin AUC and
19,20
toxicity has been established. A dose equation that takes GFR, body weight, and a target AUC into account has
20
been proposed and is shown to accurately predict myelosuppression. Given that most cats experience no clinical
toxicity from carboplatin-related myelosuppression, however, it may not be necessary to calculate a specific cat’s
GFR prior to administering a dose of carboplatin. Most cats are treated with carboplatin with the dose ranges
described above. This author empirically reduces the dose of carboplatin in cats with pre-existing renal disease to
2
150-180 mg/m to mitigate the increased risk of toxicity in those patients.
2
Overall, clinical and pharmacokinetic evidence supports doses of 200-240 mg/m every 3 to 4 weeks in cats
with carboplatin. Caution should be used in cats with pre-existing renal disease.
Alkylating Agents
Alkylating agents are some of the most commonly used chemotherapy drugs in cats. A relatively large
amount of information is available about the use of these drugs in cats, and because most clinicians are familiar with
Track B
them (particularly cyclophosphamide, chlorambucil, and lomustine), this section will focus on significant toxicities
(such as the myelosuppression associated with lomustine) and novel dosing and delivery methods.
Two dose evaluation studies of lomustine have been performed in cats. The first study concluded that a
2 21
dose of 50 to 60 mg/m once every 6 weeks is recommended. The 6 week interval between doses was suggested
because the neutrophil nadir can occur between 7 and 28 days after treatment and takes up to 14 days to resolve.
Neutropenia is the dose limiting toxicity of lomustine in cats. The second study evaluated cats that received one 10
2
mg capsule per dose regardless of their size, resulting in doses ranging from 32 to 59 mg/m . Significant toxicity was
22
uncommon in that study, likely due to the relatively low dose of lomustine received by many of the cats. Because of
263
the severity of the toxicity it is worth noting a case report that described sudden death associated with pulmonary
23
fibrosis after chronic (12 months) treatment with lomustine in one cat. In contrast to dogs, lomustine-related
24
hepatotoxicity appears to be uncommon in cats.
25
Metronomic dosing of cyclophosphamide has been described recently in cats. The median weekly dose of
2
cyclophosphamide was 66 mg/m , and cats received a varied number of doses per week. Of the 24 cats included in
this retrospective study, 29% experienced toxicity during the first 4 weeks of treatment. The toxicities were mild to
moderate and were primarily gastrointestinal. Among the 15 cats that were treated longer than 4 weeks, three
developed decreased renal function. It is difficult to determine how many of these toxicities were attributable to
cyclophosphamide only as the majority of cats in the study were receiving concurrent medications such as NSAIDs
and toceranib phosphate. No cat exhibited signs of sterile hemorrhagic cystitis.
Intraperitoneal administration of chemotherapy drugs in cats has previously been reported for cats with
26
lymphoma with similar outcome results compared to traditional intravenous and oral dosing. Depending on the cat,
intraperitoneal dosing may be better tolerated and safer for the person administering the drug. The bioavailability of
IP versus IV cyclophosphamide was recently found to be 76% in healthy cats, confirming that this method of drug
27
delivery may be reasonable, and even preferable, for some cats.
Vinca Alkaloids
Similar to the alkylating agents, vincristine is commonly used to treat cats with cancer, specifically
lymphoma. A recent study describes a new method of administration of vincristine. Fewer reports focus on a related
drug, vinblastine. These topics will be described in this section.
Intraperitoneal administration of chemotherapy drugs in cats has previously been reported for cats with
24
lymphoma with similar outcome results compared to traditional intravenous and oral dosing. Depending on the cat,
intraperitoneal dosing may be better tolerated and safer for the person administering the drug. The bioavailability of
IP versus IV vincristine was recently found to be 100% in healthy cats, confirming that this method of drug delivery
may be reasonable, and even preferable, for some cats.
The primary side effects of vincristine are gastrointestinal in nature, which can make distinguishing between
chemotherapy toxicity and progressive cancer challenging, particularly in cats with gastrointestinal lymphoma. A
recent randomized single-blinded controlled trial comparing COP-based chemotherapy protocols containing
28
vincristine versus vinblastine in cats with lymphoma compared the efficacy and toxicity between the two drugs. The
efficacy was similar between the two drugs. Cats in the vincristine group were significantly more likely to experience
gastrointestinal toxicity that was severe enough to warrant treatment group crossover. Myelosuppression occurred
more frequently in the vinblastine group, but the number of cats that had dose reductions due to neutropenia were
not significantly different between the two groups.
Table 2. Summary of doses, side effects and therapeutic indications in cats for the conventional chemotherapy
drugs discussed in this session. Dose-limiting and/or most common clinically significant toxicities are noted.
Drug Dose Toxicity Tumor Types References

2
Doxorubicin 1 mg/kg; 25 mg/m Anorexia, weight Lymphoma, mammary 11-15
loss, renal carcinoma, soft tissue
dysfunction sarcoma
Carboplatin 200 mg/m2 every 4 Myelosuppression Carcinomas, soft tissue 17-20
2
weeks; 240 mg/m sarcomas
every 3 weeks
2
Lomustine 50 to 60 mg/m every 6 Myelosuppression Lymphoma, mast cell tumors 21
weeks
2
Vinblastine 1.5 mg/m Myelosuppression Lymphoma 28
Conclusion
Multiple studies focus on the pharmacokinetics, dosing, and toxicity of anti-cancer drugs in cats, and for
many drugs a reasonable amount of evidence supports current recommendations regarding dosage, dosing interval,
and monitoring. Fewer studies have rigorously examined the efficacy of these drugs in different feline cancers, and
even fewer studies compare the effectiveness of different drugs for the same type of cancer. More studies
Track B
evaluating the efficacy of individual and combinations of anti-cancer drugs in feline tumors are needed.
References
1. Lachowiczn JL, Post GS, Brodsky E: A phase I clinical trial evaluating imatinib mesylate (Gleevec) in tumor-
bearing cats. J Vet Intern Med 19:860, 2005.
2. Isotani M, Tamura K, Yagihara H, et al: Identification of a c-kit exon 8 internal tandem duplication in a feline
mast cell tumor case and its favorable response to the tyrosine kinase inhibitor imatinib mesylate. Vet
Immunol and Immunopathol 114:168, 2006.
264
3. Isotani M, Yamada O, Lachowicz JL, et al: Mutations in the fifth immunoglobulin-like domain of kit are
common and potentially sensitive to imatinib mesylate in feline mast cell tumors. Br J Haematol 148:144,
2009.
4. Katayama R, Huelsmeyer MK, Marr AK, et al: Imatinib mesylate inhibits platelet-derived growth factor activity
and increases chemosensitivity in feline vaccine-associated sarcoma. Cancer Chemother Pharmacol 54:25,
2004.
5. Daly M, Sheppard S, Cohen M, et al: Safety of masitinib in healthy cats. J Vet Intern Med 25:297, 2011.
6. Bellamy F, Bader T, Moussy A, et al: Pharmacokinetics of masitinib in cats. Vet Res Commun 33:831, 2009.
7. Lawrence J, Saba C, Gogal R, Jr, et al: Masitinib demonstrates anti-proliferative and pro-apoptotic activity in
primary and metastatic feline injection-site sarcoma cells. Vet Comp Oncol 10:143, 2012.
8. Turek M, Gogal R, Jr, Saba C, et al: Masitinib mesylate does not enhance sensitivity to radiation in three
feline injection-site sarcoma cell lines under normal growth conditions. Res Vet Sci 96:304, 2014.
9. Frank R, Merritt D, Lesman S, et al: Exploratory safety and toxicokinetic study in cats treated with toceranib,
an oral multireceptor tyrosine kinase inhibitor. Vet Comp Oncol 8:153, 210.
10. Hohenhaus A, Henry C, Greene S, et al: Biological activity and adverse event profile in cats treated with
toceranib phosphate. Vet Comp Oncol 9:e20, 2011.
11. O’Keefe DA, Schaeffer DJ: Hematologic toxicosis associated with doxorubicin administration in cats. J Vet
Intern Med 6:276, 1992.
12. O’Keefe DA, Sisson D, Gelberg HB, et al: Systemic toxicity associated with doxorubicin administration in
cats. J Vet Intern Med 7:309, 1993.
13. Mahoney JA, Bergman PJ, Camps-Palau MA: Treatment of doxorubicin extravasation with intravenous
dexrazoxane in a cat. J Vet Intern Med 21:872, 2007.
14. Reiman RA, Mauldin GE, Mauldin GN: A comparison of toxicity of two dosing schemes for doxorubicin in the
cat. J Feline Med Surg 10:324, 2008.
15. Hahn KA, Frazier DL, Cox SK, et al: Effect of infusion regime on doxorubicin pharmacokinetics in the cat. J
Am Anim Hosp Assoc 33:427, 1997.
16. Knapp DW, Richardson RC, DeNicola DB, et al: Cisplatin toxicity in cats. J Vet Intern Med 1:29, 1987.
17. Hahn KA, McEntee MF, Daniel GB, et al: Hematologic and systemic toxicoses associated with carboplatin
administration in cats. Am J Vet Res 58:677, 1997.
18. Kisseberth WC, Vail DM, Yaissle J, et al: Phase I clinical evaluation of carboplatin in tumor-bearing cats: a
veterinary cooperative oncology group study. J Vet Intern Med 22:83, 2008.
19. Bailey DB, Rassnick KM, Erb HN, et al: Effect of glomerular filtration rate on clearance and myelotoxicity of
carboplatin in cats with tumors. Am J Vet Res 65:1502, 2004.
20. Bailey DB, Rassnick KM, Dykes NL, et al: Phase I evaluation of carboplatin by use of a dosing strategy
based on a targeted area under the platinum concentration-versus-time curve and individual glomerular
filtration rate in cats with tumors. Am J Vet Res 70:770, 2009.
21. Rassnick KM, Gieger TL, Williams LE, et al: Phase I evaluation of CCNU (lomustine) in tumor-bearing cats. J
Vet Intern Med 15:196, 2001.
22. Fan TM, Kitchell BE, Dhaliwal RS, et al: Hematological toxicity and therapeutic efficacy of lomustine in 20
tumor-bearing cats: critical assessment of a practical dosing regimen. J Am Anim Hosp Assoc 38:357, 2002.
23. Skorupski KA, Durham AC, Duda L, et al: Pulmonary fibrosis after high cumulative dose nitrosurea
chemotherapy in a cat. Vet Comp Oncol 6:120, 2008.
24. Musser ML, Quinn HT, Chretin JD: Low apparent risk of CCNU (lomustine)-associated clinical hepatotoxicity
in cats. J Feline Med Surg 14:871, 2012.
25. Leo C, Stell A, Borrego J, et al: Evaluation of low-dose metronomic (LDM) cyclophosphamide toxicity in cats
with malignant neoplasia. J Feline Med Surg 16:671, 2014.
26. Teske E, van Lankveld AJ, Rutteman GR. Intraperitonal antineoplastic drug delivery: experience wth a
cyclophosphamide, vincristine, and prednisolone protocol in cats with malignant lymphoma. Vet Comp Onc
12:37-46, 2012.
27. Voorhorst MJ, van Maarseveen EM, van Lankveld AJ, et al: Bioavailability of cyclophosphamide and
vincristine after intraperitoneal administration in cats. Anticancer Drugs 25:1211, 2014.
28. Krick EL, Cohen RB, Gregor TP, Salah PC, Sorenmo KU. Prospective clinical trial to compare vincristine and
vinblastine in a COP-based protocol for lymphoma in cats. J Vet Intern Med 27:134, 2013.
Track B
NOTES:
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NOTES:
Track B
266
Less Common Cat Cancers

Introduction
Lymphoma is the most commonly diagnosed cancer in cats, and the bulk of the literature regarding feline
oncology pertains to this subject. Although lymphoma is the top differential for any cat suspected to have cancer,
due to its wide variety in clinical presentation and behavior, several other cancers have been described in cats. This
session will focus on describing controversies with the diagnosis and management of these cancers as well as new
information regarding treatment and prognosis.
Mammary Carcinoma
Mammary tumors are the third most common tumor in cats, accounting for 17% of tumors in female cats, and
1
a minimum of 85% are malignant. Mammary carcinomas rarely occur in male cats, and the clinical course of the
2
disease seems to be similar in male and female cats. Exposure to exogenous estrogens and progestins can
increase the risk of feline mammary tumors, including a case series of 3 male cats who developed mammary
3,4,5
carcinoma after long-term exposure to medroxyprogesterone acetate. There is a protective effect against
mammary tumors in cats that are spayed prior to 1 year of age, but this benefit has not been established for cats who
4,6
are spayed later in life.
Diagnosis and Staging

Because the majority of feline mammary tumors are malignant, cytological evaluation of a mammary mass is
unlikely to change the recommendation of surgical removal and biopsy. The exception would be if there is a clinical
suspicion that a mammary mass in cat is not actually of mammary origin. In that case cytology could be performed
to confirm or rule out that suspicion. Recommending staging tests (regional lymph node evaluation and chest
radiographs, possibly abdominal ultrasound) prior to surgery is more practical, as the results of those tests may
change the expectations for prognosis and thus treatment recommendations and decisions for the patient. If staging
tests and pre-operative bloodwork results do not reveal metastasis or significant co-morbidities, then surgical
removal is the treatment of choice. There are several options for the extent of surgery for feline mammary tumors,
and that will be discussed in the Treatment section below.
Once the mass has been removed and submitted for biopsy, oncologists will use information about tumor
grade to make further treatment recommendations. Tumor grade has historically been associated with outcome after
7
surgery, with cats with high grade tumors having shorter survival times compared to those with low grade tumors. A
more recent study compared the current grading system for feline mammary carcinoma (which is based on human
breast cancer) with prognosis, examined which histopathological features were associated with prognosis, and
8
proposed a modified feline-specific grading system for mammary carcinomas. One hundred and seven samples
were included from cats that had no treatment for their mammary carcinoma other than surgery. Grade according to
the original system was not associated with survival time, but grade according to the newly proposed grading system
revealed significant differences in outcome according to grade. Cats with Grade I tumors had a median survival time
of 31 months, Grade II 14 months, and Grade III 8 months. Specific histopathological criteria that were associated
with survival on multivariate analysis included lymphovascular invasion, mitotic count, and abnormalities in the shape
of the nucleus. The specific tumor-related reason for death (metastasis, new tumor development, local recurrence)
was not noted, however, and this information is needed to allow clinicians to make treatment recommendations
based on the proposed grading system. The type of surgery performed (marginal versus radical) was also not noted,
and that could have affected the survival numbers as well.
Treatment
Surgery is the primary treatment modality for feline mammary carcinoma. Because most FMC are locally
aggressive, typically an aggressive surgery is recommended: unilateral radical mastectomy for cats with tumors on
1
one side of the mammary chain and bilateral radical mastectomy for cats with bilateral tumors. However, when one
looks for evidence to support this recommendation, it is difficult to find. No survival advantage after radical surgery
Track B
was found compared to more conservative surgery in one study, and another study found no difference in outcome
9,10
between cats that had regional versus radical mastectomy and unilateral versus bilateral radical mastectomy. Not
all studies completely support those findings, however, as cats that had a bilateral radical mastectomy had a
significantly longer survival than cats that had a unilateral radical mastectomy or a regional mastectomy on
11
univariate, but not multivariate, analysis in a more recent study. It is possible that owners of cats with very
aggressive local or metastatic disease elected for more conservative surgery, which could have confounded those
results.
267
The information missing or poorly reported from the studies described above is the actual cause of death for
most cats (particularly for cats with radical vs. conservative surgeries): local recurrence, new mammary carcinoma
or metastatic disease. One recent report found that 67% of the cats that died by the end of the study had pulmonary
metastatic disease, while another paper reports that of the cats that developed progressive disease, most had local
9,12
recurrence of the original primary tumor or another mammary tumor. If metastatic disease is the primary cause of
death even for patients that undergo conservative surgery, then a radical surgery may not translate into a significant
enough benefit to make it worth the added morbidity and cost.
The role of chemotherapy in feline mammary carcinoma is even more controversial. The outcome of
adjuvant chemotherapy with doxorubicin-based protocols has been evaluated retrospectively, and no significant
10,11,12
survival advantage has been documented compared to no adjuvant treatment. It is possible that owners of cats
with high grade tumors are more likely to pursue chemotherapy. If that is the case, then perhaps chemotherapy is
effective in increasing the survival time of those cats to bring it closer to cats with low grade tumors that have not
received chemotherapy.
New Prognostic Factors

Additional studies have looked for the presence of certain molecular markers in feline mammary carcinoma
as potential prognostic factors and therapeutic targets. Feline mammary carcinomas with increased expression of
Ki-67 (a protein expressed in dividing cells) are more likely to have lymph node and/or distant metastasis at
13,14
diagnosis and a shorter survival time. Ki-67 expression was positively correlated with some other negative
8
prognostic factors, such as larger tumor size, higher grade of tumor, necrosis, and lack of estrogen receptors.
Expression of human epidermal growth factor receptor-2 (HER-2) is an important prognostic indicator and
therapeutic target in women with breast cancer, and several studies have looked for this overexpression and possible
15-19
association with prognosis in feline mammary carcinoma. The results have been mixed—one study found that
70% of feline mammary carcinomas overexpressed HER-2, while another study found overexpression in only 5.5%
15,16
of samples. Three other studies found more similar numbers regarding to the percentage of tumors that
overexpress HER-2 but reported disparate results regarding the association of HER-2 overexpression with other
17-19
prognostic factors. The percentage of tumors with HER-2 overexpression ranges from 33% to 59.6% in these
studies. One concluded that HER-2 expression was associated with survival but not grade, while the other found
that it was associated with tumor grade, tumor size and lack of estrogen and progesterone receptors in the tumor.
Although the results of are mixed, it seems that HER-2 may be a therapeutic target for feline mammary carcinoma.
Indeed, a study examining the immunological effects of administering a DNA vaccine for HER-2 in healthy cats has
20
yielded promising results.
Mast Cell Tumors

Cutaneous
Surgical excision is the treatment of choice for cats with solitary or few cutaneous mast cell tumors. The
completeness of surgical excision is not a prognostic factor for recurrence, so a marginal excision is considered
21
sufficient. If surgical removal is not an option due to tumor size and location, then radiation therapy can be used.
Response rates for feline cutaneous mast cell tumors to radiation therapy have not been reported, and either
definitive or palliative courses can be used depending on the particular cat’s clinical condition and expected
prognosis. If localized therapy is not appropriate given the extent of cutaneous lesions, then systemic therapy can be
considered.
Cytotoxic options for feline cutaneous mast cell tumors that have been reported include lomustine and
TM 22,23,24
imatinib mesylate (Gleevec ). No studies evaluating the efficacy of vinblastine for feline mast cell tumors have
been published. Treatment of 11 cats with mast cell tumors with imatinib has been reported, and 8 of them had
23,24
some degree of tumor regression. A multi-center retrospective study of the use of lomustine to treat feline mast
24
cell tumors found a response rate of 50% in cats with primary cutaneous tumors. Supportive care for these patients
includes glucocorticoids to reduce inflammation and possible cytotoxic effects, H1 and H2 blockers, and antibiotic
and analgesic treatment as needed.
The prognosis for cats with solitary cutaneous mast cell tumors is excellent following surgical removal;
however, these cats are likely to develop additional mast cell tumors in the future. The effect of lymph node
metastasis on prognosis is unknown. In the author’s experience, some cats with numerous cutaneous mast cell
tumors can live for several months or more with stable or slowly progressive disease and a good quality of life.
Track B
25,26
Mitotic index has recently been shown to be associated with survival in cutaneous mast cell tumors. The median
mitotic index for cats dying of mast cell disease within 2 years of diagnosis was significantly higher compared to the
25
median mitotic index of cats alive for more than 2 years after the diagnosis (3.5 versus 1.0, p < 0.002). Mitotic
26
index > 5 is associated with shorter survival after surgery in cats with cutaneous mast cell tumors.
Visceral
Cats with visceral mast cell disease are more likely to exhibit clinical signs such as vomiting, diarrhea,
constipation, or lethargy, depending on the anatomic location involved (GI tract, spleen, liver, etc.), and they may
268
also exhibit signs of mast cell degranulation. An abdominal mass and/or splenomegaly may be noted on abdominal
palpation. Systemic mast cell disease may be suspected if mast cells are noted on a blood smear, though the
27,28
quantity of mast cells seen does not necessarily correlate with extent of systemic disease. Cytology is often
sufficient for the diagnosis. Staging tests such as buffy coat evaluation and/or bone marrow aspirate may be
recommended. Chest radiographs can be performed to assess the sternal lymph node.
Similar to cutaneous tumors, surgical excision is the treatment of choice for cats with splenic mast cell
tumors. Mast cell disease was the most common reason (53%) for splenectomy in a small study evaluating the
29
outcome of splenectomy in 19 cats. The long-term prognosis of cats with splenic mast cell disease post
30
splenectomy is relatively good. The role of adjuvant chemotherapy for these patients is unclear and in the author’s
opinion it is not recommend given the lack of evidence for any efficacy and the expected prognosis with surgery
alone. If surgery is not performed, chemotherapy and any necessary supportive care can be administered, though
the effect on outcome is unknown.
Cats with intestinal mast cell tumors will exhibit clinical signs related to the mass. They may also have
intermittent clinical signs indicating degranulation episodes. Even with surgical removal the prognosis has historically
been considered grave. A very recent study of 15 cats with intestinal mast cell tumors found that 7 of the 13 cats
available for follow up survived more than 1 year after diagnosis. The cats received a variety of treatments, and four
out of nine cats that underwent intestinal mass resection lived less than 1 month after surgery due to surgical
31
complications. Cats with intestinal mast cell tumors may have gastrointestinal ulcers, so sucralfate may be
recommended as well.
Hemangiosarcoma
Presentation and Diagnosis
Hemangiosarcoma is an aggressive soft tissue sarcoma, and it most commonly manifests in the cutaneous
or subcutaneous tissue and visceral organs in cats. The distribution of visceral versus subcutaneous or cutaneous
lesions was equal in one report, though a more recent study found that 77% of cases of feline hemangiosarcoma
were of cutaneous or subcutaneous origin, with cutaneous locations being more likely than subcutaneous
32,33
locations.
Cats with visceral hemangiosarcoma may present with hemoperitoneum or have a palpable abdominal
mass. A study characterizing the clinical presentation and diagnosis (pre or post mortem) for cats with spontaneous
hemoperitoneum found that 46%of cats had abdominal neoplasia, and hemangiosarcoma was the most commonly
34
diagnosed neoplasia in the population (60% of cats with neoplasia). The spleen was the most common site for
hemangiosarcoma (37% of cats with neoplasia) in that study. Hemangiosarcoma was the second most common
diagnosis (21%) associated with splenectomy in cats in one study of 19 cats who had undergone splenectomy for a
29
variety of reasons. A retrospective study describing visceral hemangiosarcoma in cats found that the liver (35%)
35
was the most common site. Hemoperitoneum was diagnosed in 54% of those cats, and the majority of cats (77%)
had involvement of more than one site at diagnosis. Pulmonary metastasis was detected in 19% of cats at
32
diagnosis. An earlier study reported that 60% of cats with visceral hemangiosarcoma had metastasis at diagnosis.
Hemangiosarcoma can metastasize to the abdominal and/or thoracic cavities in cats, so recommended staging tests
include chest radiographs or CT scan and abdominal ultrasound. The extent of pre-surgical staging performed
depends on the status of the patient—more would be recommended for a stable cat with a subcutaneous mass
suspected to be hemangiosarcoma compared to an unstable cat with hemoperitoneum.

Surgical excision is the treatment of choice when feasible for cats with hemangiosarcoma, though the
outcome following surgery is varied. One study reported that local recurrence of cats with cutaneous
hemangiosarcoma did not occur despite incomplete margins in some cats, compared to a 50% rate of local
33
recurrence (all associated with prior incomplete excision) in cats with subcutaneous hemangiosarcoma.
Reported prognostic factors in that study included tumor location, completeness of surgical margins, and
33
mitotic index. Cutaneous lesions were associated with significantly longer survival compared to subcutaneous and
visceral locations, and subcutaneous lesions are associated with longer survival compared to visceral locations.
Cats with completely excised subcutaneous lesions have significantly longer survival compared to cats with
incompletely excised subcutaneous lesions. A study specifically evaluating outcome in cats with cutaneous and
subcutaneous hemangiosarcoma found that cats that underwent surgical excision, regardless of the completeness of
Track B
the margins, had a significantly longer survival time compared to cats in which surgery was not attempted (>1460
36
versus 60 days, respectively, p=0.0004).
Visceral hemangiosarcoma is associated with a relatively short survival time after surgery and discharge
from the hospital (median 77 days); however, given the high percentage of euthanasia at the time of surgery or
before surgery is even attempted, the number of cats with visceral hemangiosarcoma that have surgery and are
35
discharged from the hospital is quite low. It is possible that different visceral locations may be associated with
different outcomes (such as spleen versus liver), but such a comparison has not been reported.
269
The use of adjuvant chemotherapy and radiation therapy for cats with cutaneous, subcutaneous, and
visceral hemangiosarcoma is infrequently reported, and the efficacy of such treatment has not been specifically
evaluated. Overall, the prognosis for cats with visceral hemangiosarcoma is grave with many cats being euthanized
or developing metastatic disease shortly after surgery. In contrast, the prognosis for cats with cutaneous
hemangiosarcoma is relatively good, with long survival times being reported following surgical excision. The
prognosis for cats with subcutaneous hemangiosarcoma varies depending on the feasibility of complete surgical
excision.
Multiple Myeloma
Multiple myeloma is a systemic cancer of plasma cells. Unlike many cancers, the diagnosis of multiple
myeloma (versus plasma cell tumor) is a clinical one. If patients meet at least 2 of 4 criteria, then they are
considered to have multiple myeloma. These criteria include monoclonal gammopathy, Bence Jones proteinuria,
lytic bone lesions, and bone marrow plasmacytosis. The accuracy of these criteria to diagnose multiple myeloma in
cats has recently come into question, with differing conclusions about the frequency of skeletal lesions in feline
multiple myeloma and the documentation of frequent liver and spleen involvement. This information has led to
changes in the diagnostic work-up for cats suspected to have multiple myeloma. Prognosis for cats with multiple
myeloma remains controversial as well, with a wide variety of survival times reported. Although melphalan is the
historically recommended medical treatment for multiple myeloma, it carries the risk of significant myelosuppression.
Alternatives, such as cyclophosphamide, have been recently reported.
Diagnostic Criteria
The first retrospective study describing the clinical manifestation of multiple myeloma in cats found that the
most common criteria found in cats with multiple myeloma were monocolonal gammopathy and bone marrow
37
plasmacytosis, occurring in 10.0% and 93.3% of cats tested, respectively. Lytic bone lesions and Bence jones
proteinuria were less common, occurring in 50% and 44.4% of cats tested, respectively. They also documented liver,
spleen, and/or lymph node involvement in seven of the sixteen cats (though not all cats were evaluated for such
involvement) and propose that liver and/or spleen involvement be included in the diagnostic criteria for multiple
myeloma in cats. A later study found that 67% of cats with myeloma-related diseases had extramedullary (liver,
spleen, and/or skin) involvement, but lytic bone lesions were rare occurring in just one of the 13 cats evaluated for
38
that abnormality. Both of these studies showed that the minority of cats were hypercalcemic, in contrast to multiple
37,38
myeloma in other species. A last retrospective study by the same authors describing additional features of
multiple myeloma in cats found that of 19 cats with well-differentiated myeloma-related disease, 79% had abdominal
39
organ and/or skin involvement. A contrasting study by a different author found that six of nine cats with multiple
40
myeloma had lytic bone lesions, and the presence of abdominal organ involvement was not described.
Given the majority of the information in the literature regarding multiple myeloma in cats, in the author’s
opinion it is reasonable to alter the diagnostic criteria for this species to include liver and/or spleen involvement and
even consider removing the presence of lytic bone lesions from the criteria. In our practice we now recommend
abdominal ultrasound as part of routine staging for feline patients with plasma cell tumors and/or suspicion of multiple
myeloma.

The response to treatment for cats with multiple myeloma is variable. Patel et al describe survival times
37
ranging from 1 to 6 months when cats were treated with prednisone and melphalan. When all cats that received
chemotherapy were combined in the later study, the median survival time with treatment was 284 days for all cats
38
and 373 days for cats that responded to treatment. Prognostic factors identified for myeloma-related diseases in
cats include whether the neoplastic cells are well or poorly differentiated and type of treatment, with cats underdoing
specific treatment for multiple myeloma having significantly longer survival compared to cats that received supportive
39
care only or no treatment. Two cats in these studies experienced significant neutropenia while receiving melphalan
38
chemotherapy, severe enough to lead to euthanasia in one of those cats. Another study also documented
neutropenia associated with melphalan chemotherapy in cats with multiple myeloma.
Treatment with a COP-based chemotherapy protocol was described in one study but specific outcome with
38
that protocol was not reported. Oral cyclophosphamide has been used successfully to treat cats with multiple
myeloma at the author’s institution with less frequent neutropenia episodes and increased convenience for owners.
Track B
For cats in which the administration of oral medications is particularly difficult, it may be preferable to treat once a
week with cyclophosphamide compared to two to three times a week with melphalan.
References
1. Lana SE, Rutteman GR, Withrow SJ: Tumors of the mammary gland. In Withrow SJ and Vail DM, editors:
Withrow and MacEwen’s Small Animal Clinical Oncology, ed 4, Saunders Elsevier, 2007, p 619.
2. Skorupski KA, Overley B, Shofer FS, et al: Clinical characteristics of mammary carcinoma in male cats. J Vet
Intern Med 19:52, 2005.
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3. Hayes AA, Mooney S. Feline mammary tumors. Veterinary Clinics of North America: Small Animal Practice
1985;15(3):513-520
4. Misdorp W, Romijn A, Hart AMM. Mammary tumors: a case-control study of hormonal factors. Anticancer
Research 1991;11:1793-1798.
5. Jacobs TM, Hoppe BR, Poehlmann CE, Ferracone JD, Sorenmo KU. Mammary adenocarcinomas in three
male cats exposed to medroxyprogesterone acetate (1990-2006). Journal of Feline Medicine and Surgery
2010;12:169-174.
6. Overley B, Shofer FS, Goldschmidt MH, Sherer D, Sorenmo KU. Association between ovarihysterectomy
and feline mammary carcinoma. Journal of Veterinary Internal Medicine 2005;19:560-563.
7. Castagnaro M, Casalone C, Bozzetta E, et al: Tumour grading and the one-year post-surgical prognosis in
feline mammary carcinomas. J Comp Pathol 119:263, 1998.
8. Mills SW, Musil KM, Davies JL, et al: Prognostic value of histologic grading for feline mammary carcinoma: a
retrospective survival analysis. Vet Pathol 52:238, 2015.
9. Ito T, Kadosawa T, Mochizuki M, et al: Prognosis of malignant mammary tumor in 53 cats. J Vet Med Sci
58:723, 1996.
10. Borrego JF, Cartagena JC, Engel J.Treatment of feline mammary tumours using chemotherapy, surgery and
a COX-2inhibitor drug (meloxicam): a retrospective study of 23 cases (2002–2007). Vet Comp Oncol 7:213,
2009.
11. Novosad CA, Bergman PJ, O’Brien MG, McKnight JA, Charney SC, Selting KA, Graham JC, Correa SS,
Rosenberg MP, Gieger TL. Retrospective evaluation of adjunctive doxorubicin for the treatment of feline
mammary gland adenocarcinoma: 67 cases. Journal of the American Animal Hospital Association
2006;42:110-120.
12. McNeill CJ, Sorenmo KU, Shofer FS, Gibeon L, Durham AC, Barber LG, Baez JL, Overley B. Evaluation of
adjuvant doxorubicin-based chemotherapy for the treatment of feline mammary carcinoma Journal of
Veterinary Internal Medicine 2009;23:123–129.
13. Castagnaro M, De Maria R, Bozzetta E, Ru G, Casalone C, Biolatti B, Caramelli M. Ki-67 index as indicator
of the post-surgical prognosis in feline mammary carcinomas. Research in Veterinary Science 65:223, 1998.
14. Soares M, Ribeiro R, Carvalho S, et al: Ki-67 as a prognostic factor in feline mammary carcinoma: what is
the optimal cutoff value? Vet Pathol epub ahead of print, doi:10.1177/0300985815588606, 2015.
15. Rasotto R, Caliari D, Castagnaro M, et al: An immunohistochemical study of HER-2 expression in feline
mammary tumours. J Comp Pathol 144:170, 2011.
16. Winston J, Craft DM, Scase TJ, et al: Immunohistochemical detection of HER-2/neu expression in
spontaneous feline mammary tumors. Vet Comp Oncol 3:8, 2005.
17. Soares M, Correia J, Rodrigues P, et al: Feline HER2 protein expression levels and gene status in feline
mammary carcinoma: optimization of immunohistochemistry (IHC) and in situ hybridization (ISH) techniques.
Microsc Microanal 19:876, 2013.
18. Millanta F, Calandrella M, Citi S, et al: Overexpression of HER-2 in feline invasive mammary carcinomas: an
immunohistochemical survey and evaluation of its prognostic potential Vet Pathol 42:30, 2005.
19. Ordas J, Millan Y, Dios R, et al: Proto-oncogene HER-2 in normall, dysplastic and tumorous feline mammary
glands: an immunohistochemical and chromogenic in situ hybridization study. BMC Cancer 7:179, 2007.
20. Gibson HM, Veenstra JJ, Jones R, et al: Induction of HER2 immunity in outbred domestic cats by DNA
electrovaccination. Cancer Immunol Res epub ahead of print, DOI: 10.1158/2326-6066.CIR-14-0175, 2015.
21. Molander-McCrary H, Henry CJ, Potter K, et al: Cutaneous mast cell tumors in cats: 32 cases (1991-1994). J
Am Anim Hosp Assoc 34:281, 1998.
22. Isotani M, Tamura K, Yagihara H, et al: Identification of a c-kit exon 8 internal tandem duplication in a feline
mast cell tumor case and its favorable response to the tyrosine kinase inhibitor imatinib mesylate. Vet
Immunol and Immunopathol 114:168, 2006.
23. Isotani M, Yamada O, Lachowicz JL, et al: Mutations in the fifth immunoglobulin-like domain of kit are
common and potentially sensitive to imatinib mesylate in feline mast cell tumors. Br J Haematol 148:144,
2009.
24. Rassnick KM, Williams LE, Kristal O, et al: Lomustine for treatment of mast cell tumors in cats: 38 cases
(1999-2005). J Am Vet Med Assoc 232:1200, 2008.
25. Melville K, Smith KC, Dobromylskyj MJ: Feline cutaneous mast cell tumors: a UK-based study comparing
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signalment and histological features with long-term outcomes. J Feline Med Surg 17:486, 2015.
26. Sabattini S, Guadagni Frizzon M, Gentilini F, et al: Prognostic significancy of Kit receptor tyrosine kinase
dysregulations in feline cutaneous mast cell tumor. Vet Pathol 50:797, 2013.
27. Garrett LD, Craig CL, Szladvits B, et al: Evaluation of buffy coat smears for circulating mast cells in healthy
cats and ill cats without mast cell tumor-related disease. J Am Vet Med Assoc 231:1685, 2007.
28. Piviani M, Walton RM, Patel RT: Significance of mastocytemia in cats Vet Clin Pathol 42:4, 2013.
29. Gordon SS, McClaran JK, Bergman PJ, et al: Outcome following splenectomy in cats. J Feline Med Surg
12:256, 2010.
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30. Henry C, Herrera C. Mast cell tumors in cats: clinical update and possible new treatment avenues. J Feline
Med Surg 15:41, 2013.
31. Sabattini S, Giantin M, Barbanera A, et al: Feline intestinal mast cell tumors: clinicopathological
characterization and KIT mutation analysis. J Feline Med Surg epub ahead of print DOI:
10.1177/1098612X15581205, 2015.
32. Scavelli TD, Patnaik AK, Mehlfaff CJ, et al: Hemangiosarcoma in the cat: retrospective evaluation of 31
surgical cases. J Am Vet Med Assoc 187:817, 1985.
33. Johannes CM, Henry CJ, Turnquist SE, et al: Hemangiosarcoma in cats: 53 cases (1992-2002). J Am Vet
Med Assoc 231:1851, 2007.
34. Culp WT, Weisse C, Kellogg ME, et al: Spontaneous hemoperitoneum in cats: 65 cases (1994-2006). J Am
Vet Med Assoc 236:978, 2010.
35. Culp WT, Drobatz KJ, Glassman MM, et al: Feline visceral hemangiosarcoma J Vet Intern Med 22:148,
2008.
36. McAbee KP, Ludwig LL, Bergman PJ, et al: Feline cutaneous hemangiosarcoma: a retrospective study of 18
cases (1998-203).
37. Patel RT, Caceres A, French AF, et al: Multiple myeloma in 16 cats: a retrospective study. Vet Clin Pathol
34:341, 2005.
38. Mellor PJ, Haugland S, Murphy S, et al: Myeloma-related disorders in cats commonly present as
extramedullary neoplasms in contrast to myeloma in human patients: 24 cases with clinical follow-up. J Vet
Intern Med 20:1376, 2006.
39. Mellor PJ, Haugland S, Smith KC, et al: Histopathologic, immunohistochemical, and cytologic analysis of
feline myeloma-related disorders: further evidence for primary extramedullary development in the cat. Vet
Pathol 45:159, 2008.
40. Hanna F: Multiple myelomas in cats J Feline Med Surg 7:275, 2005.
NOTES:
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Top Oncology Mistakes and How to Avoid Them: Part 1&2

See Something Do Something. Why Wait? Aspirate

Don’t Monitor The Bump or Lump. Do Get an Aspirate or Biopsy
Visual monitoring of skin and subcutaneous masses is not enough. Even the most experienced veterinarian
or oncologist cannot look at or palpate a mass and know whether it is malignant or not. Cancer is a cellular
diagnosis! It is always recommended to evaluate masses that are growing, changing in appearance, or irritating to
the patient. But these guidelines are not enough.
TM
“See Something Do Something ” (SSDS) provides guidelines for evaluating superficial masses in dogs and
cats. These guidelines will increase client awareness and will promote early cancer detection, diagnosis, and early
surgical intervention. In veterinary medicine, most skin and subcutaneous tumors can be cured with surgery
alone if diagnosed early when tumors are small.
o See Something: When a skin mass is the size of a pea (1 cm) and has been present for at least 1 month,
o Do Something: Aspirate or biopsy, and treat appropriately!
Why diagnose early? Obtaining a definitive diagnosis with cytology or biopsy early and before excision will
lead to improved patient outcomes for superficial masses. Surgery is likely curative for the majority of superficial
tumors when detected early when they are small - especially benign lesions and tumors that are only locally invasive
with a low probability of metastasis. If tumors are removed with complete surgical margins, the prognosis is often
good with no additional treatments needed.
o Pet owners need to be aware of the “pea” size requirement to have masses evaluated
o Veterinarians must measure and document the size of the mass in order to compare growth.
o If > 1 cm (or size of large pea) and present for a month, the mass should be aspirated or biopsied.
o Knowing the tumor type prior to the FIRST surgery will increase success of a curative-intent surgery.
Don’t Remove a Mass Without Knowing What It Is

Do Get an Aspirate or Biospy Before the Surgery to Remove the Whole Mass
REMEMBER, THE FIRST SURGERY IS BEST CHANCE FOR CURE for many tumors. For a skin or
subcutaneous mass, the extent of surgery is changed by tumor type or potentially grade. If it’s a benign skin tumor, a
st
marginal resection is fine, but for a malignant tumor such as a soft tissue sarcoma (STS), the 1 surgery should be
wide. If it is in challenging location like a distal limb or a head and neck tumor, consider a boarded surgeon to do the
st
1 surgery.
Aspirate and Cytology

Fine needle aspiration (FNA) and cytology provide a diagnosis for many skin and SQ masses, especially
those that that exfoliate well. FNA is useful to distinguish neoplasia from inflammation. Cellular morphology may also
allow for the determination of benign or malignant phenotype. FNA is useful for identifying benign masses including
lipomas and sebaceous adenomas. For malignant tumors, cytology provides information that assists in formulating
diagnostic and treatment plans.
The advantages of cytology include that it is a minimally invasive, low risk, low cost procedure, and results
are available more quickly than are biopsy results. The disadvantages of cytology are that it may be non-diagnostic
or equivocal. This may be due to a small number of cells in the sample, poor exfoliation of the cells, or poor sample
quality. If the sample is non-diagnostic or equivocal, histopathological confirmation may be required for definitive
diagnosis. Unless the sample is comprised exclusively of only fat, clear cystic fluid, or acellular debris, the sample
should be submitted to a trained cytopathologist. WHEN IN DOUBT, SEND IT OUT. Including an adequate history
helps the pathologist in diagnostic accuracy.
Biopsy
Track B
If cytology is non-diagnostic, a pre-treatment biopsy is recommended PRIOR to complete tumor removal.

The pre-treatment biopsy will determine the optimal treatment plan.
The role of excisional biopsy is controversial, even among oncologic surgeons. 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.
It is tempting to remove the mass right away. An excisional biopsy establishes a diagnosis and removes the
tumor at the same time. However it is not recommended for undiagnosed skin and superficial masses. Malignant
273
tumors often require 2 to 3 cm margins. When an excisional biopsy (or debulking surgery) leads to incomplete
margins for malignant tumors, more treatment, more morbidity, and more expense ensue. Thus removing the mass
entirely is not recommended without a cellular diagnosis prior to definitive excision. Surgical approaches
vary with different tumor types. Research confirms that the first surgery is the best chance for a cure.
Staging diagnostics are often indicated prior to curative intent surgery. Consultation with a veterinary oncologist is
recommended.
Don’t Let the Pet Owners Decide About Biopsy Submission

Do Submit any Mass you Remove to the Lab
Every mass removed should be submitted and examined by a pathologist.at the lab. If you remove had 4
masses, all 4 should go to the lab – even if you think the masses look benign. Histopathology is the only way to know
tumor type, grade, and for margin evaluation. And do not assume the owner won’t treat if its cancer; many
reconsider once they learn that cancer is often treatable and treatment can be well tolerated.
If it is important enough to remove, it is important enough to submit for histopathology.
Don’t Assume Clean Surgical Margins were Clean

Do Ask the Pathologist to Report Margins and Consider if this is Wide Enough for this Tumor Type
I often see cats months after a tumor was removed and then grew back. When I read the original biopsy
report, it will often read: margins were clean. Good news, right? BUT when I read the microscopic decision, the
measurement will say <1 mm. For a malignant tumor, this is not clean. For many malignant tumors 2 to 3 cm are
recommended. For example, feline STS are highly locally invasive and often recur with incomplete margins.
I am surprised how often this important detail is overlooked. For a benign skin tumor like a basal cell tumor
or a benign liver tumor, margins of a few millimeters may be adequate. But malignant tumors require wider margins.
So, remember, size matters! Ask how wide the margins were (get numbers) and ask if that is wide enough for this
tumor type. If you are not sure, consult with an oncologist.
Don’t Treat Cats like small Dogs when giving Chemotherapy

Chemotherapy is well tolerated in dogs and cats. 80% of animals that receive chemotherapy therapy have no
side effects, and cats tend to tolerate chemotherapy better than dogs. In my experience, 15-20% of pets have mild
side effects, and this is even less common in cats. Similarly it is rare to cause such severe side effects that require
hospitalization. If this does occur, these patients are usually hospitalized for typically 24-48 hours with supportive
care including IV fluids and antibiotics.
Some chemotherapy drugs are dosed differently in cats. For example there is now a better method to more
accurately dose carboplatin in cats based on glomerular filtration rate, which is determined with an Iohexol clearance
test.
Side effects in cats are also different. Nadirs (or the low white blood cell count) in cats can vary. For oral
Lomustine, the expected nadir can vary significantly from 7 to 28 days. Cardiotoxicity is a well-described adverse
effect in dogs treated with doxorubicin, but it has not been reported in cats. Cats do not appear to develop sterile
hemorrhagic cystitis after the use of cyclophosphamide. Unlike dogs, concurrent administration of furosemide is not
recommended in cats.
Don’t be Afraid to refer to a Specialist

Surgery
Boarded surgeons are more aggressive at surgery - in a good way. Studies show that for malignant tumors
(i.e. injection site sarcomas); patients often have better outcomes when the surgery is done by a specialist. Why? By
st
removing more tissue the 1 time, they are more likely to get those clean and WIDE margins and prevent the need
for a second scar revision surgery. Surgeons are trained in advanced techniques like flaps which can help get
margins. In the long run, this will save the client money (1 surgery vs. 2), less treatment, less morbidity, and better
recovery. Boarded surgeons are often trained in proper biopsy and surgery techniques to avoid tumor contamination
and spread at time of surgery.
Oncology
The oncologist provides the most current and comprehensive treatment options and newest available
Track B
prognostic data. I counsel the client about most appropriate options.

I will also adjust staging based on budget and the individual case. I adjust treatment protocols based on response
and tolerance. And I work with primary care vet and other specialists to provide comprehensive care.
As an oncologist, I have advanced training in cancer. My expertise and experience is the management of
cancer patients. And I give chemotherapy therapy – lots of it. You want an expert when it comes to these drugs, side
effects, and current protocols. When it comes to general health – you, the family veterinarian, is the expert and one
to turn to. The family veterinarians are the experts in preventative health care, nutrition, vaccines, thyroid disease,
274
kidney failure, diabetes, general surgery, and geriatric pet health. And I send my cases back to the family vet for
management of those issues. But when it comes to cancer, in my opinion, you should refer to an oncologist.
Don’t Think you Must Perform the Staging Diagnostics Before you Refer to the Oncologist
I sometimes see lymphoma patients who are told these ALL need to be done before they come see me. But
then they decide not to treat, so those tests are a waste of money and time.
In other cases, the pet owner may have a limited budget for diagnostics and treatment. Depending on the
case and the cancer, I will discuss the pros and cons on eliminating certain staging tests. If a cat with lymphoma is
having difficulty breathing, I will strongly encourage we get the chest radiographs. While it is ideal to perform
complete staging tests, it may not be practical in all case. So we may make an educated to skip the chest
radiographs in some cases of gastrointestinal lymphoma.
If we are going to do a CT scan of one area of the body (such as of the head for an oral or nasal tumor), we
can cost effectively also CT the chest, which is a better test to look for chest metastasis. So I recommend holding on
the chest X-rays prior to referral if CT is recommended for a case.
But for other cases, I may skip certain tests and apply those funds towards treatment. It’s less about a
checklist of tests, and more about what is important and needed in each case. I will adjust staging based on budget
and patient needs.
rd
Finally, if you are taking chest radiographs, please don’t forget the 3 view when taking chest radiographs.
Don’t Assume your Client Would Never Treat the Pet for Cancer, Especially with Chemotherapy, or because
the Pet is too Old
When first told their pet has cancer, a reflex reaction of pet owner is to say they are against chemotherapy
therapy. But it is not uncommon for that same owner to treat after meeting me. Do I convince them to treat? Of
course not, but I do replaced myths with facts, fears with hope and knowledge.
80% of animals that receive chemotherapy therapy have no side effects, and cats tend to tolerate
chemotherapy better than dogs. In my experience 15-20% of pets have mild side effects. About 5% of chemotherapy
patients have severe side effects that require hospitalization for typically 24-48 hours, and this is even less common
in cats. Most patients are feeling better with IV fluids, injectable nausea meds and antibiotics. In addition, with dose
reductions and medications to prevent further side effects, most of my patients can receive that same chemotherapy
drug again without any issues – the same chemotherapy drug that landed them in ICU the last time.
It is a myth that the pet will feel crappy all the time, that they suffer during treatment, and they will be
hospitalized all the time. Pets undergoing chemotherapy feel good - not just after chemotherapy but during the
protocol too.
And remember, giving chemotherapy to a pet is not a contract. If the owners do not like how the pet is
handling it, we can stop. I never force people to continue, but I do encourage them to try a dose or two if they are
considering treating. Most pet Guardians are so surprised and pleased with the chemotherapy and the quality of life
while undergoing chemotherapy, they return with their pet for more treatments. So it can be useful for the owners to
meet with the specialist and learn about the options. Even if they decide not to treat, they will have made an
educated decision.
Don’t say the pet is too old. Age is not a disease. I have many 15-plus year old feline patients that are
otherwise healthy and strong. They may have some early kidney disease, a heart murmur, or thyroid disease, but
they are still “treatable” cancer patients. Don’t assume the pet won’t tolerate treatment. Many pets not only live longer
but live better with treatment than without.
Don’t think there are no Options for Pets with Advances Disease like Metastasis
Traditional chemotherapy is given at the maximum tolerated dose (MTD) chemotherapy. MTD chemotherapy
is the dose level for an individual chemotherapy drug that produces acceptable dose limiting toxicity (DLT). The DLT
is considered the clinically acceptable/ manageable side effects at cytotoxic doses. Chemotherapy is most active in
rapidly proliferating cells. The cellular targets include DNA, RNA, and proteins. The result is irreparable damage that
leads to apoptosis and necrosis. MTD is typically not effective for dogs with advance macroscopic metastatic
disease.
On the other hand, metronomic chemotherapy is pulse or low-dose continuous chemotherapy. This is
typically administered daily or every other day. The target is endothelial cells in that line tumor blood vessel. The goal
Track B
may be tumor is stabilized, but this prevents further growth and spread. Common chemotherapy drugs include
Palladia, cyclophosphamide, and chlorambucil. There is still much to be learned including best drugs, dose,
schedule, tumor types, and toxicity.
Don’t think Radiation = Bad Side Effects

CyberKnife Radiosurgery or Stereotactic RadioSurgery (SRS) is non-invasive, frameless system that uses
multiple beams to deliver single fraction or hypofractionated RT with submillimeter accuracy. The large number of
275
beams with continuous image-guidance during treatment allows high conformation around the tumor and greater
precision than traditional linear accelerators and IMRT machines.
The unique robotic delivery decreases toxicity, improves targeting with submillimeter accuracy, and allows
treatment in fewer fractions - 1 or 3 treatments (conventional radiation is usually 20 treatments). Since less normal
tissue is irradiated, there are fewer treatments, less anesthesia, decreased side effects, good tumor control, fewer
hospital visits, and less worry by the pet owner.
CyberKnife is used instead of surgery and treats macroscopic disease, not microscopic. CyberKnife is used
when “blade” surgery impossible, would cause unacceptable morbidity, or is refused. CyberKnife can also be used if
conventional radiation has failed and can be used to retreat cases that have already had SRS.
st
The Animal Specialty Center was the 1 to use CyberKnife in pets and has been treating using since March 2008.
We have treated over 750 cases. Which tumors can we treat with CyberKnife Stereotactic RadioSurgery?
Treatment of Choice:
o Brain tumors, Nasal Tumors (lymphoma and ACA)
o Oral tumors especially maxillary, Spinal tumors, Re-treatments
Useful case by case:
o Appendicular and axial OSAs, soft tissue sarcomas, lung tumors, thymoma.
NOTES:
Track B
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See Something, Do Something. Why wait? Aspirate.™

What is See Something, Do Something?

“See Something, Do Something” (SSDS) is a lumps and bumps cancer awareness program that provides
guidelines for evaluating superficial masses in dogs and cats. We hope these guidelines to increase client awareness
will promote early cancer detection and diagnosis, as well as early surgical intervention. In veterinary medicine,
most skin and subcutaneous tumors can be cured with surgery alone if diagnosed early when tumors are
small.
o See Something: If a skin mass is the size of a pea (1 cm) and has been there 1 month,
Why do we need SSDS?

It is well documented that cytologic and histologic evaluations are important diagnostic tools in veterinary
oncology and that obtaining a preliminary diagnosis optimizes treatment planning. It is also recommended to
evaluate masses that are growing, changing in appearance, or irritating to the patient. At this time, no specific
guidelines exist for determining when to aspirate or biopsy or when to monitor canine and feline skin and
subcutaneous masses.
Without standard of care guidelines, superficial masses may be monitored for too long. This can negatively
impact our patient’s prognosis as well as limit their treatment options. Tumors that are diagnosed later and are larger
may require more advanced treatments. Surgical excision of larger masses may result in less than adequate surgical
margins (narrow or incomplete), leading to recurrence and additional costly therapy (second more aggressive local
surgery, radiation therapy and/or chemotherapy).
With significant time delays and prolonged monitoring, there may be no reasonable surgical treatment
options to remove large advanced tumors. These are often the most frustrating and heartbreaking cases.
Why Diagnose Early?

Obtaining a definitive diagnosis with cytology or biopsy early and before excision will lead to improved
patient outcomes for superficial masses. Surgery is likely curative for the majority of superficial tumors when detected
early when they are small - especially benign lesions and tumors that are only locally invasive with a low probability
of metastasis. If tumors are removed with complete surgical margins, the prognosis is often good with no additional
treatments needed.
o Visual monitoring is not enough.

o Pet owners need to be aware of the “pea” size requirement to have masses evaluated
o Veterinarians must measure and document the size of the mass in order to compare growth.
o If > 1 cm (or size of large pea) and present for a month, the mass should be aspirated or biopsied.
o Knowing the tumor type prior to the FIRST surgery will increase success of a curative-intent surgery.
What are the Most Common Feline Tumors?

Primary skin and subcutaneous tumors are common in dogs and cats. While the overall incidence in dogs
and cats is difficult to determine, approximately 25 to 43% of biopsies submitted in dogs and cats are of the skin.
Of submitted samples, 20 to 40% are reported to be malignant.
In cats, the most common superficial tumors include basal cell tumors (15-26%), mast cell tumors (13-21%),
squamous cell carcinomas (10-15%), fibrosarcomas (15-17%), and sebaceous gland adenomas (2-4%).
Is Visual Monitoring Acceptable?

Even the most experienced veterinarian or oncologist cannot look at or palpate a mass and know whether it
is malignant or not. Cancer is a cellular diagnosis! It is always recommended to evaluate masses that are growing,
changing in appearance, or irritating to the patient. But these guidelines are not enough. All skin and SQ masses that
Track B
are >1 cm and have been present for 1 month should be aspirated for cytologic evaluation. Biopsy is indicated if
cytology does not provide a diagnosis.
Methods of Diagnosis
Aspirate and Cytology
Fine needle aspiration (FNA) and cytology provide a diagnosis for many skin and SQ masses, especially
those that that exfoliate well. FNA is useful to distinguish neoplasia from inflammation. Cellular morphology may also
allow for the determination of benign or malignant phenotype. FNA is useful for identifying benign masses including
277
lipomas and sebaceous adenomas. For malignant tumors, cytology provides information that assists in formulating
diagnostic and treatment plans.
The advantages of cytology include that it is a minimally invasive, low risk, low cost procedure, and results
are available more quickly than are biopsy results.
The disadvantages of cytology are that it may be non-diagnostic or equivocal. This may be due to a small
number of cells in the sample, poor exfoliation of the cells, or poor sample quality. If the sample is non-diagnostic or
equivocal, histopathological confirmation may be required for definitive diagnosis.
Unless the sample is comprised exclusively of only fat, clear cystic fluid, or acellular debris, the sample
should be submitted to a trained cytopathologist. WHEN IN DOUBT, SEND IT OUT. Including an adequate history
helps the pathologist in diagnostic accuracy.
Biopsy
If cytology is non-diagnostic, a pre-treatment biopsy is recommended PRIOR to complete tumor removal.
The pre-treatment biopsy will determine the optimal treatment plan.
The role of excisional biopsy is controversial, even among oncologic surgeons. 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.
It is tempting to remove the mass right away. An excisional biopsy establishes a diagnosis and removes the
tumor at the same time. However it is not recommended for undiagnosed skin and superficial masses. Malignant
tumors often require 2 to 3 cm margins. When an excisional biopsy (or debulking surgery) leads to incomplete
margins for malignant tumors, more treatment, more morbidity, and more expense ensue. Thus removing the mass
entirely is not recommended without a cellular diagnosis prior to definitive excision. Surgical approaches
vary with different tumor types. Research confirms that the first surgery is the best chance for a cure.
Staging diagnostics are often indicated prior to curative intent surgery. Consultation with a veterinary
oncologist is recommended.
After the Aspirate/Biopsy

If the mass is benign:
Benign tumors may not need to be removed. A variety of factors, including mass location should be
considered. Surgery should be recommended when a benign tumor is causing pain, irritation, bleeding, or infection.
Surgery should also be recommended if an increase in growth would prevent a surgery in the future.
Alternatively, if removing the tumor requires a complicated surgery (i.e. near a joint, on the distal limb with
minimal surrounding tissue for reconstruction) or the pet has other pre-exiting issues, you and the pet owner may
make an educated decision as to whether proceeding to surgical removal is warranted. PETS WITH MASSES NOT
REMOVED SHOULD BE MONITORED (via measurement) BY THE VETERINARIAN EVERY 3 to 6 MONTHS.
If surgery is performed, most benign masses require smaller surgeries, as wide margins are typically not
needed.
If the mass is malignant:

If the aspirate/biopsy reveals malignancy, consult with veterinary oncologist for appropriate staging
recommendations. For malignant tumors, the first surgery should be a wide excisional surgery.
If wide excisional surgery is not possible due to the size or anatomic location of the mass, consultation with a
veterinary oncologist or board-certified surgeon is indicated. Surgeons may be able to perform specialized surgeries
such as axial pattern flaps to remove the tumor completely.
Debulking (cytoreductive) surgery may not be recommended, as this will not obtain margins, and additional
post-operative treatments such as radiation will be required to prevent recurrence. In some cases, cytoreductive
surgery may be performed for palliation, or with an understanding that adjunctive therapy such as radiation therapy
will follow the procedure.
After surgery:
o Review the histopathology report – tumor type, grade, vascular and lymphatic invasion.
o Consult with a veterinary oncologist for additional therapeutic considerations for malignant tumors.
Track B
o Assess the QUANTITY of surgical margins in consideration of tumor type and biologic behavior. (One mm
margins for a malignant tumor may be called “clean” on a biopsy report, but size of margins must be
considered in light of tumor histology.)
o If margins are inadequate, recommend adjunctive treatment before tumor recurrence for optimum patient
outcome. Post-operative options include scar revision (second surgery), radiation to prevent regrowth, or
chemotherapy which may slow recurrence in some cases.
o It is important to consult a board certified surgeon before attempting scar revision.
278
o Monitor for local tumor recurrence and metastasis as indicated by the histologic diagnosis and margin
assessment.
Recurrence and Monitoring

Patients with reported complete surgical margins can potentially suffer tumor recurrence due to microscopic
cancer extension that is not seen in the evaluated sections. Therefore, it is essential to monitor for local regrowth,
and to recruit the pet owner to monitor the surgical scar as well, to identify early relapse.
For malignant tumors with wide, clean margins and low metastatic potential, follow-up rechecks are
recommended every two to three months after the surgery for as much as one year of follow up. Early detection is
key to addressing recurrence and metastasis to ensure the highest possible chance of success.
Owners are encouraged to check their pets regularly at home for new masses.
o Owners should check their pet monthly for superficial masses by noting their location and size.
o Create a “body map” with size and location of superficial masses recorded, along with fine needle aspiration
cytology results. This body map can serve as an objective medical record document and owner guide to
follow masses longitudinally, and to allow for identification of new masses over time.
o All masses should be aspirated and submitted for cytology. Masses that do not need cytologic assessment
include lipomas, cysts, and those containing acellular debris.
o If cytology is non-diagnostic, discuss repeating the aspirate, or proceeding to biopsy.
o Know the tumor type prior to surgery. The first surgery is your patient’s best chance for cure.
Surgery May be all that is Needed

We all must be proactive to advocate for early cancer detection. Visual monitoring of superficial masses is
not enough. Obtaining a definitive diagnosis via either cytology or biopsy early and before excision will lead to
improved patient outcomes for superficial masses. Surgery is likely curative for the majority of these cases,
especially for benign masses and those locally invasive malignancies that are non-metastatic. If tumors are
detected and removed earlier – when they are small and with clean margins, the prognosis is often good and
the patient may not require additional therapy.
o See Something: When a skin mass is 1 cm and has been present for 1 month,
Early detection saves lives. Why wait? Aspirate?™
NOTES:
Track B
279
NOTES:
Track B
280
Practical Take-home Tips for Managing Feline Cancer Patients in Your Practice
Cancer is not a death sentence in pets. Chemotherapy is well tolerated in the majority of cats undergoing
treatment. With treatment, many cats are not only living longer, but living well.
Importance of Oncology
The pet is a family member, and owners often want same standard of care for their cats as they do
themselves. Sadly, cancer is leading cause of death in pets.
“Cancer” is a scary word that is often equated with death. There is often a visceral fear of cancer, and people
think cancer equals pain and suffering. Owners think cancer treatment will just make the patient sicker. With cancer,
there is no hope. I disagree. Cancer is not a death sentence. While we all want a cure for cancer, I encourage
thinking about many cancers as chronic conditions that may require chronic therapy, such as kidney or heart
disease. As an oncologist, I recommend treatment when the pet is likely to live longer with it than without. Thankfully,
most cats feel good, if not great, during treatment. I believe it is important to approach the topic of cancer with
knowledge, compassion, and a positive attitude.
Approach to Tumors
o What is it?
o Suspicion: Owner complaint/history, Physical exam
o Definitive Diagnosis:
 FNA and cytology
• Methods: Fenestration, Aspiration
• Advantages and Disadvantages
• Find masses and get a diagnosis early
• See Something, Do Something. Why wait? Aspirate
o See Something: When a skin mass is the size of a pea (1 cm) and has been
present for at least 1 month,
 Biopsy and histopathology
• Biopsy Methods:
o Incisional - needle core, punch, wedge
o Excisional
• Why biopsy before definitive treatment?
o Willingness to treat
o Cytology is questionable
o Decide optimal treatment plan
• General Biopsy Principles
o Proper biopsies DO NOT spread cancer
o Good technique: Do not squeeze. Careful hemostasis. Avoid seromas, Do
not “spill” the cancer! (pleural, peritoneal), Change packs between, No
penrose drains
• Planning Biopsy Site
o Removable with definitive excision
o Legs and tails - longitudinal!
o Lines of tension
• Handling Biopsy Tissue:
o Always submit for histopathology
o Mark your margins - ink, suture
o Use proper fixation, 1:10 of tissue:10% formalin
Track B
o Separate containers
o Do not forget the history!
o Where is it? Staging
o CBC, chemistry panel, UA
o Regional lymph node analysis
o Thoracic radiographs Why Three-View Radiographs?
o Abdominal ultrasound
o Ideal to fully stage BUT… Knowing pathophysiology is critical
281
o CT scan
o MRI
o How bad is it? Prognostic factors
o Individual patient factors
o Extent of local disease
o Results of staging
o Concurrent illness
o Disease related factors
o Biological behavior
o Grading systems
What can we do about it? Treatment Modalities

Local-regional disease typically involves surgery and/or radiation.
Surgery alone: It is important to know type of tumor before surgery excision. Knowing the tumor type prior to
the FIRST surgery will increase success of a curative-intent surgery. For skin and superficial masses, obtaining a
definitive diagnosis with cytology or biopsy early and before excision will lead to improved patient outcomes.
When in doubt, send the cytology 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.
Surgery is likely curative for the majority of superficial tumors when detected early when they are small -
especially benign lesions and tumors that are only locally invasive with a low probability of metastasis. If tumors are
removed with complete surgical margins, the prognosis is often good with no additional treatments needed.
For internal tumors, pre-operative cytology or biopsy are not always possible (i.e. lung tumors) but advanced imaging
such as CT scan can be useful prior to surgery.
Radiation Therapy
Radiation can be used for curative intent or palliative intent. Conventional radiation is typically used post-
operatively for microscopic disease, though it may be recommend before surgery. Conventional radiation typically
involves daily fractionation – small doses are given daily over 15 to 20 treatments.
A newer radiation option is stereotactic radiosurgery (SRS) or stereotactic radiation therapy (SRT). While this
is also curative intent, it is used on macroscopic disease. SRT is used in place of surgery, typically for inoperable
tumors. The most common tumors we treat at Animal Specialty Center are brain and nasal tumors. One of the main
benefits of SRT compared to conventional radiation is its precision, which means less damage to the surrounding
healthy tissue. Since less normal cells are included in the radiation field, fewer treatments and less treatment
sessions are needed than conventional radiation. A nasal tumor for example might require 15 to 20 treatments with
conventional radiation, but only 3 treatments with CyberKnife SRS. This means less anesthesia sessions and fewer
side effects. However CyberKnife is not a good option for all types of tumors. For example incompletely removed
soft tissue sarcomas are not good candidates for CyberKnife SRS.
Radiation side effects are typically divided into early and late. Acute/early side effects involve rapidly dividing
st
tissues, such as the skin, mucous membranes, gastrointestinal tract. These typically occur within the 1 2-4 weeks
after radiation. Late side effects involve the more slowly dividing tissues including bone and nervous tissue.
Secondary tumors are an uncommon late complication.
An alternative approach is palliative radiation. This is typically used for large, bulky, non-resectable tumors. A
typical palliative protocol is weekly for 3 to 4 weeks. The goal of this radiation is to make the cat more comfortable. In
general there are less acute side effects than with definitive radiation, but there is greater potential for late effects.
This is the trade off, and most of these cases will not usually have long term control.
Systemic Disease/Metastatic Disease: Chemotherapy

Conventional Chemotherapy: Conventional chemotherapy is typically given at high dosages, known as
maximum tolerated dose, or MTD. The goal is to kill the rapidly dividing cancer cells. But some normal cells that also
have high turnover often can be temporarily damaged by MTD chemo. Most commonly, it is the GI tract cells and the
neutrophils that are temporarily damaged. As a result there is a break period to allow these cell populations to
recover. MTD is typically given weekly to every 3 weeks.
Track B
Chemotherapy drugs attack rapidly dividing cells. The normal tissues that typically are most sensitive to
chemotherapy are the bone marrow, hair follicles (alopecia), and the gastrointestinal lining. This is often referred to
as “BAG”.
Bone marrow suppression most commonly results in a neutropenia but cats seem to be more tolerant than
dogs. Neutrophils and platelets are at greatest risk due to the shorter circulating lifespan, and shorter bone marrow
transit times. Neutropenia is the dose-limiting toxicity in veterinary oncology.
When giving a potentially myelosuppressive drug like doxorubicin, carboplatin and Lomustine, I personally
like to check the expected nadir (low neutrophil count) to see if antibiotics and/or a dose reduction are needed. The
282
nadir typically occurs 7 days after chemo administration. Pay attention to the neutrophil count, not the total white
blood cell count. For some chemotherapy drugs the nadir in cats is more variable such as carboplatin and Lomustine.
For these, the nadir is can occur 7 to 28 days after treatment. Chlorambucil tends to cause delayed neutropenias and
thrombocytopenias after chronic use.
Alopecia (hair loss) is due to damaging the rapidly dividing hair follicle. In cats, alopecia is rare, but shaved
areas tend to grow back more slowly (limb catheters, abdominal ultrasounds). Cats more commonly lose their
whiskers. The good news is that hair and whiskers will re-grow once the treatments have completed. Occasionally,
hair will grow back a different texture or color. In cats it is typically softer, aka the “chemo coat”. It is important to
remember cats do not care about this cosmetic side effect, and it does not impact the quality of life. However, cat
owners like to be advised about the whiskers so they are not surprised.
Gastrointestinal (GI) toxicity includes vomiting, diarrhea, decreased appetite, nausea. It typically 1 to 5 days
after chemotherapy and is self-limiting – lasting on average 2-3 days. Again, these side effects are less common in
feline chemotherapy patients than dogs. I often will use off label Cerenia or mirtazapine as needed.
How Toxic is Chemotherapy?

The overall toxicity rate is very low in veterinary chemotherapy patients. 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.
If there are side effects, I also typically will add prophylactic medications to prevent side effects like nausea,
vomiting or diarrhea as indicated. If the side effects are more severe, the drug type or dosage may be adjusted at
subsequent treatments to minimize the chance of side effects recurring.
When a chemotherapy drug is used that is known to have a high potential for bone marrow suppression, a
complete blood count (CBC) is often checked after the treatment to see if the WBC are low. Antibiotics may be
prescribed as a preventive measure. Subsequent doses of chemotherapy are adjusted based on the results of the
CBC. Unlike dogs, I do not routinely use prophylactic antibiotics or GI medications unless the cat had issues with a
prior treatment.
In my experience, there is less than a 5% chance that a cat will need hospitalization. If this does occur, these
patients are usually hospitalized for typically 24-48 hours with supportive care including IV fluids and antibiotics. In
my experience most chemotherapy patients can successfully receive that drug again with a dose reduction.
Metronomic Chemotherapy
In contrast to MTD chemotherapy, metronomic chemotherapy is pulse or low-dose continuous
chemotherapy. This is typically administered daily or every other day. The target is endothelial cells in that line tumor
blood vessel. The goal may be tumor is stabilized, but this prevents further growth and spread. Common
chemotherapy drugs include Palladia, cyclophosphamide, and chlorambucil and also with NSAIDS. There is still
much to be learned including best drugs, dose, schedule, tumor types, and toxicity. This can be considered for some
cats with advanced metastatic disease.
What to do at the Nadir Visit?

In addition to running a CBC, it is important to get a good history, TPR (that temperature is so important in
chemotherapy patients), and a complete physical examination. I am always interested in knowing how the cat
handled chemo –did she eat well, any vomiting/diarrhea, did the owner use any nausea or diarrheal medications?
For the exam, did he lose weight, was she febrile? The nadir CBC should not be a technician appointment to just pull
the blood sample.
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 (see above). 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.
Also, I prefer that we get blood samples from the jugular veins for cats getting IV chemotherapy (unless
thrombocytopenic).Save those peripheral veins for treatment please. Finally many times the oncologist has run a
recent chemistry panel, so check with the oncologist, and try not to repeat unneeded blood work to keep costs down.
Track B
In addition to the chemotherapy targeting rapidly dividing bone marrow stem cells, other mechanisms for
neutropenia includes bone marrow infiltration with neoplastic cells (leukemia, advanced stage lymphoma, multiple
myeloma) and increased consumption due to infection.
283
Neutrophil count Fever, systemic signs Plan
(per uL)
1500-2500 No Monitor
+/- treatment delay 2 to 4 days
<1500 No Oral antibiotics
Generalist
treatment delay
Consider dose change
<1500 yes ATH for IVF & IV antibiotics
treatment delay
dose change
Don’t Treat Cats like Small Dogs when it comes to Chemotherapy

Some chemotherapy drugs are dosed differently in cats. In dogs, weight and body surface area are used to
determine the carboplatin dose. In cats there is now a more accurate method to dose carboplatin in cats based on
glomerular filtration rate, which is determined with an Iohexol clearance test.
Side effects in cats are also different. Cardiotoxicity is a well-described adverse effect in dogs treated with
doxorubicin, but it has not been reported in cats. Sterile hemorrhagic cystitis (SHC) is a relatively uncommon
complication of cyclophosphamide in dogs and ifosfamide therapy in dogs and cats. SHC is typically associated with
long-term use, but possible after single dose, and can progress to bladder fibrosis. The incidence with
Para-professional
cyclophosphamide has been reported to be 9% in dogs (7-24%), 3% in cats, and 24% in humans. Unlike dogs,
concurrent administration of furosemide with cyclophosphamide is not recommended in cats. Mesna, which binds the
SHC-inducing acrolein, is recommended for cats when administering ifosfamide.
Oncology Pearls
o Don’t say “it’s cancer; there is nothing we can do.”
o Age is not a disease.
o Don’t vaccinate cats between the shoulder blades
o If it is important enough to remove, it is important enough to get histopathology.
o Perform 3-view thoracic radiographs for cancer staging.
o 80% of cats that receive chemotherapy have no side effects.
o Cats tolerate chemotherapy better than dogs.
o Chemotherapy is not a contract.
o See Something, Do Something. Why wait? Aspirate.™
o I am not a microscope.
o Early detection saves lives.
o Cancer is not a death sentence.
o Live longer, live well.
NOTES:
Advanced
Track B
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Lunch & Learn
Lunch
Diarrhea Dilemma: What We Think We Know About Treatment of IBD
Generalist
Susan Little, DVM, DABVP (Feline)
Introduction
& Learn
Idiopathic inflammatory bowel disease (IBD) is a common chronic enteropathy of cats that is immunologically
mediated. Clinic signs are persistent or recurrent and include vomiting, diarrhea, weight loss, and hyporexia. Mucosal
inflammation is most often found in the small intestine, but can involve any part of the gastrointestinal (GI) tract. The
cause of IBD is not fully understood, but research suggests genetic factors influencing the mucosal immune system,
dietary factors, and enteric bacteria play important roles.
Diagnosis
Currently, the diagnosis is one of exclusion and requires intestinal biopsy to differentiate IBD from other
disorders such as lymphoma. The diagnostic approach starts with a thorough patient history (including dietary
history) and physical examination. Initial diagnostic testing (e.g., fecal analysis, complete blood count, serum
Para-professional
chemistry profile, urinalysis, total T4, feline leukemia virus and feline immunodeficiency virus testing) is designed to
confirm or refute the presence of primary GI disease. Further testing may focus on the GI tract, such as serum feline
TLI and PLI, cobalamin, and folate. Advanced diagnostics that may be useful include imaging (radiography,
ultrasonography) and biopsy (intestinal tract, liver, mesenteric lymph nodes, pancreas) via endoscopy, laparotomy, or
laparoscopy. The preferred method of intestinal biopsy – endoscopic versus full thickness – is a subject of
controversy. Recommendations have been published for maximizing diagnostic yield when performing GI endoscopy
1,2
and should be reviewed by clinicians using this approach. The clinician should initially focus on ruling in or out
parasitic causes, infectious causes, GI disease requiring surgery (such as a foreign body), exocrine pancreatic
insufficiency, and non-GI disease. Once these disorders have been eliminated, the most common diagnoses for GI
signs in the cat are idiopathic IBD, diet-responsive enteropathy, and alimentary lymphoma. While biopsy is used to
diagnose IBD and lymphoma, the distinction between severe IBD and lymphoma is not always easy to make based
on histopathology and may require immunophenotyping (B cell/T cell markers) or PCR (clonal expansion of
lymphocytes) for confirmation.
Treatment
Treatment for IBD in cats remains empirical as data is lacking or inadequate. In humans and in dogs with
IBD, quantifiable indices are used to measure clinical disease. An index has been suggested for cats – the feline
chronic enteropathy activity index (FCEAI) – where the magnitude of the score correlates with the degree of
3
inflammation. The index is used to assess response to treatment and to tailor medical therapy to the individual
patient. It can be applied to patients with IBD or diet-responsive enteropathy.
Although grading systems have been proposed, no standardized histopathologic evaluation of biopsy
samples has been validated for disease severity or outcome. Until pathologists can agree on a standard grading
scheme, lesions are subjectively classified. In some cases (such as intestinal infiltration with neutrophils or
macrophages), culture, special stains, or fluorescence in situ hybridization may be indicated. Results could determine
which patients are best treated with antibiotics and/or probiotics.
Studies in cats with chronic lymphoplasmacytic enteropathy have found that most patients respond to
treatment with diet, antibiotics, or immunosuppressive drugs. Sequential treatment helps determine which treatment
4
will be most effective for the individual patient. Using this approach, a diet trial is performed first for at least 7 days
and response is assessed. Most cats will benefit from long term dietary therapy even if other treatments are
necessary. The next step is a 14-day trial of metronidazole (15 mg/kg PO daily); if clinical signs improve, the dose is
tapered by 25% every 2 weeks until it is discontinued. Cats that are non-responsive to diet and metronidazole are
treated with oral prednisolone (2 mg/kg PO daily) alone or in combination with metronidazole. The prednisolone dose
is tapered by 25% every 2 weeks to reach the lowest dose that controls clinical signs. Other immunosuppressive
medication choices include chlorambucil (2 mg/cat PO every 72 hours) or cyclosporin (5 mg/kg PO daily). Some cats
Advanced
can be weaned from medications and maintain remission with dietary therapy alone. Cats with low serum cobalamin
should be supplemented at 250 mcg/week SC for 6 weeks, then one dose after 30 days. The serum cobalamin is
reassessed 30 days after the last dose. Some cats will require long term monthly cobalamin supplementation.
Not all owners are able to afford an optimal diagnostic investigation, including biopsies. Clinicians often must
treat suspected IBD cases without diagnostic confirmation. These patients should be treated with the sequential
therapy approach outlined above. Cats that have significant weight loss and watery small bowel diarrhea should be
treated with cobalamin parenterally. Cats with signs of large bowel diarrhea may benefit from dietary fiber
supplementation, such as ¼ teaspoon psyllium per meal. Patients that fail to respond to these treatments can be
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treated with prednisolone with the understanding that it may not be the best therapy should the patient have
lymphoma or an infectious component.
Prognosis
& Learn
Most cats with IBD respond well to treatment but some will fail due to compliance issues, severe disease,
Generalist
concurrent disease (such as hepatic or pancreatic disease, or hyperthyroidism), and misdiagnosis (especially cats
that actually have lymphoma). Low serum cobalamin has been correlated with poor clinical response in cats with
3
chronic enteropathy. A decrease in the FCEAI for a patient is associated with successful outcomes , as is a decrease
5
in serum acid glycoprotein (an acute phase protein).
Lunch
References
1. Willard MD, Mansell J, Fosgate GT, Gualtieri M, Olivero D, Lecoindre P, et al. Effect of sample quality on the
sensitivity of endoscopic biopsy for detecting gastric and duodenal lesions in dogs and cats. J Vet Intern Med
2008; 22: 1084–1089.
2. Washabau RJ, Day MJ, Willard MD, Hall EJ, Jergens AE, Mansell J, et al. Endoscopic, biopsy, and
histopathologic guidelines for the evaluation of gastrointestinal inflammation in companion animals. J Vet
Intern Med 2010; 24: 10–26.
3. Jergens AE, Crandell JM, Evans R, Ackermann M, Miles KG and Wang C. A clinical index for disease
activity in cats with chronic enteropathy. J Vet Intern Med 2010; 24: 1027–1033.
Para-professional
4. Jergens AE. Feline Idiopathic Inflammatory Bowel Disease. J Feline Med Surg 2012;14: 445–458.
5. Jergens AE, Crandell JM, Morrison JA, et al. Serum acute phase proteins in feline inflammatory bowel
disease [abstract]. J Vet Intern Med 2007; 21: 612.
NOTES:
Advanced
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Generalist Para-professional Advanced
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NOTES:
NOTES:
AMERICAN ASSOCIATION OF FELINE PRACTITIONERS
2016 FELINE PRACTICE MANAGEMENT MEETING
Feline Focused
Business Strategies
E!
March 4-6, 2016 AT
Hyatt Regency Resort Lake Tahoe, NV H ED
E T
V
SA
E!
AT AMERICAN ASSOCIATION OF FELINE PRACTITIONERS
E D
TH
V E
S A 2016 CONFERENCE
Feline Behavior and Respiratory Diseases

November 3 – 6, 2016
Washington Marriott Wardman Park Hotel

Washington, DC

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2015 American Association of

3rd World Feline Veterinary Conference

Diagnostic Imaging and Oncology

Partnering with the

www.catvets.com/education/ October 1 – 4, 2015 American Association of Feline Practitioners 1

We would like to recognize and thank the

Gold Partnership Sponsor Silver Partnership Sponsor

Silver Partnership Sponsor Silver Partnership Sponsor Silver Partnership Sponsor

Conference Sponsor Conference Sponsor Conference Sponsor

Conference Sponsor Conference Sponsor Conference Sponsor

Conference Sponsor Conference Sponsor

2 American Association of Feline Practitioners October 1 – 4, 2015 www.catvets.com/education

Pre-conference Day Sessions

End of Life Issues in Feline Medicine 1:00 – 2:00 pm

Controversies Surrounding Protein in Feline Nutrition

Emerging Infectious Diseases 4:30 – 5:30 pm

www.catvets.com/education/ October 1 – 4, 2015 American Association of Feline Practitioners 3

7:30 – 8:00 am CONTINENTAL BREAKFAST in Grand Hall Foyer

General Session: Feline Pain Management Guidelines Sponsored by

10:00 – 10:45 am NETWORKING REFRESHMENT BREAK in Exhibit Hall

Ultrasound of Feline Gastrointestinal, Improve Your Radiographic

LUNCH in Exhibit Hall

Updates in Pain Management, Dr. Michael Petty - Hillcrest A

Dental Radiography Updates Improve Your Interpretation of

3:45 – 4:15 pm NETWORKING REFRESHMENT BREAK in Exhibit Hall

Feline Bones: Musculoskeletal Review Radiographic Interpretation of Heart

Do Cats Have 9 Lives? Imaging Special Sonographic Features

6 American Association of Feline Practitioners October 1 – 4, 2015 www.catvets.com/education

TRACK A TRACK B PARA-PROFESSIONAL

BREAKFAST in Exhibit Hall

CT of the Feline Choosing & Using Radiology Understanding the Cat

NETWORKING REFRESHMENT BREAK in Exhibit Hall

Managing the Feline Cancer Patient: Part 1 Kitties in Crisis: Emergency

LUNCH in Exhibit Hall

12:45 – 1:45 pm Lunch & Learn: Sponsored by

Update on Feline Anaplasmosis, Dr. Michael Lappin – Hillcrest A

Management of Feline Neoplastic Effusions Trouble in the Urethra: Feline

www.catvets.com/education/ October 1 – 4, 2015 American Association of Feline Practitioners 7

BREAKFAST in Exhibit Hall

Secrets to Improve Quality-of-Life for Chemotherapy Drugs

NETWORKING REFRESHMENT BREAK in Exhibit Hall 10:15 – 10:45 am

LUNCH in Exhibit Hall

12:40 – 1:40 pm Lunch & Learn: Sponsored by

Kitty Oncologic Emergencies: HELP!!! See Something, Do Something. Why wait?

The Secret Weapon: Polyunsaturated Practical Take-home Tips for Managing

Conclusion of Conference 3:30 pm

www.catvets.com/education/ October 1 – 4, 2015 American Association of Feline Practitioners 9

Livia Benigni, DVM, MRCVS, CertVDI, PGCertAP, DECVDI

Elizabeth Colleran, DVM, MS, DABVP (Feline) Sponsored by

Sue Ettinger, DVM, DACVIM (Oncology)

William Folger, DVM, MS, DABVP (Feline) Sponsored by

S. Dru Forrester, DVM, MS, DACVIM Sponsored by

Lorrie Gaschen, PhD, DVM, Dr.med.vet, DECVDI Sponsored by

Erika Krick, VMD, DACVIM (Oncology) Sponsored by

Michael Lappin, DVM, PhD, DACVIM Sponsored by

Zoe Lenard, BVSc (Hons), FANZCVS (Radiology) Sponsored by

Susan Little, DVM, DABVP (Feline) Sponsored by

Erica Mattox, CVT, VTS (ECC) Sponsored by

Brook Niemiec, DVM, DAVDC, DEVDC, FAVD

12 American Association of Feline Practitioners October 1 – 4, 2015 www.catvets.com/education

THURSDAY, OCTOBER 1, 2015 – Pre-conference Day

4:30 – 5:30 pm Emerging Infectious Diseases, Dr. Susan Little

FRIDAY, OCTOBER 2, 2015