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How soon should surgery be done for sarcoma cancer?
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How soon should surgery be done for sarcoma cancer?

I hope this is the right forum for this question. My 12 year old cat was found to have a hard lump which after being tested shows high probability of sarcoma cancer. Obviously, it will need to come out but she also was just diagnosed with Hypertrophic Cardiomyopathy at the same time. So the vet is concerned that it would be dangerous to put her under with her heart like this. Her suggestion is to put her on a beta blocker (Atenolol) for a month and then do the surgery to remove this lump. (Chest x-ray looked good, no enlarged heart or cancer).
Which is best? Is it ok to put the surgery off for a month if it's cancer? How dangerous would it be to put her under, either now or after she's been on the beta blocker? And she also said the beta blocker lowers blood pressure, which I wouldn't think would be good since blood pressure tends to become lowered while being under anesthesia. I really don't know what's best here! I don't know if I should do this surgery right away or wait until she's been on this medication for awhile. I really need to hear from some other vets on your opinion, please. I want to do what's best for my cat without endangering her. Thank you so much.
April
Type of Animal
:  
cat
Age of Animal
:  
12 Years
Sex of Animal
:  
Female
Breed of Animal
:  
domesticated housecat
Last date your pet was examined by a vet?
:  
December 02, 2009
X-Ray Results
:  
Chest x-ray is clear, no sign of cancer in lungs or surrounding area and no enlarged heart.
Other pertinent test results
:  
Pathology report shows high probability of sarcoma cancer after lump was aspirated and sent to pathology.
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931217_tn?1283484935
Dear April2,

Your post asks some very valid and important questions about disease prioritization and safety of interventions which lead directly to other questions about your pet's condition, which I'm not sure are fully answered.

Regarding the heart disease diagnosis: Hypertrophic cardiomyopathy is a disease which is typically diagnosed conclusively with an echocardiogram. It is a disease which causes thickening and stiffening of the heart walls which limits proper movement, chamber filling and pumping efficiency. While an enlarged heart as seen on a radiograph (x-ray) can be consistent with this diagnosis, the absence of enlargement with a murmer, does not a diagnosis of hyperophic cardiomyopathy make. Is there a fast heart rate or abnormal heart rhythm? In other words what is the basis for using atenolol? Is the thyroid level normal? (Hyperthyroid cats may get secondary heart disease which can resolve with thyroid disease treatment.) What does the CBC, biochemical panel and urinalysis say about the cats overall systemic health? My advice? Get the echocardiogram and make sure a CBC, biochemical panel, T4 (thyroid level) and urinalysis have been done.

Regarding the sarcoma diagnosis: Remove the bulk of the mass as soon as possible, assuming there is no other undiagnosed or untreated disease which may adversely affect anesthesia. Further, if a sarcoma, surgery may not be enough to "cleanse" the tumor site of stray cells or tentacles of tumor which may remain after surgery, adjacent to blood vessels and lymphatics in the surrounding "healthy" tissue. Radiation may be necessary to follow surgery to address this. That will be determined based upon "clean" margins around the removed tumor. Removal should include a surrounding cuff of apparently healthy tissue in an attempt to get "clean" margins. Ideally the removed mass should have its cut edges painted such that a pathologist can determine how close to a cut edge any tumor cells may be. The goal is clean margins with one surgery. A wide cuff of healthy tissue (perhaps 3 cm in all directions) is required to achieve this. Not every area of the body can allow this so region of tumor matters.

One aside: a fine needle aspirate is not as accurate as a biopsy in making  a tissue diagnosis, so if the cytology was not completely conclusive which sometimes occurs, perhaps a biopsy (removing a piece of the mass for more in depth analysis) as an intervening step before major surgery to remove the entire mass is a consideration. That is for your doctor to determine based on the wording of the cytology report.

"Is it ok to put the surgery off for a month if it's cancer?" You'll have to, if the heart disease diagnosis is real. Get the echocardiogram first.

"How dangerous would it be to put her under, either now or after she's been on the beta blocker?" In the absence of heart disease no particular danger. If heart disease present, anesthesia may spark an abnormal heart rhythm which can be serious. Get the echocardiogram first. Then allow your doctor to judge the wisdom of going ahead at any given point.

"blood pressure tends to become lowered while being under anesthesia." That is only true if the anesthetist (your veterinarian and her staff together) do not take proactive measures to maintain appropriate blood pressure. Such measures include but are not limited to: veterinary technician standing by at all times to monitor and address anesthetic issues and who has no other duties during the procedure, electronic BP monitor hooked up and functioning, ECG hooked up and functioning, cat endotracheally intubated on gas anesthesia, IV in place, fluid drip underway - ready to increase rate as necessary, active methods of body temp maintenance in use, appropriate drugs nearby (dopamine, hetastarch), etc.

"I really don't know what's best here! I want to do what's best for my cat without endangering her." These sentiments are shared by every loving pet owner on the planet. It is our (veterinarians) job to explain to every pet owner how and why an intervention is done in the manner it is, and what measures are in place to minimize risk. Risk cant be eliminated, only minimized. You want a doctor who actively works to minimize risk. Sometimes the hospital he/she works in does not provide every tool, though the doctor may be other wise risk "wise." You have to communicate with your doctor and make your concerns clear. If they refuse to discuss the risk mitigation measures in place for anesthesia administration, then you may want to seek services elsewhere.

Some of us take all risk mitigation measures, but communicate that incompletely or poorly. Occasionally and unfortunately some of us take few  such measures and that also is uncommunicated. How does a pet owner tell the difference? By asking questions and by getting second opinions from disinterested third parties, such as here on MedHelp.

Often things go well in spite of less than ideal risk mitigation. When a bad result occasionally occurs, however, the risk prepared, good communicating veterinarian can honestly say that all that could have been done, was done. And the pet owner can go on without guilt. Sometimes bad things happen despite our best intentions. All we can do is be thorough, honest and good commuicators.  That is all you as a pet owner can insist on. There is no unsafe anesthesia, just unsafe anesthetists. Learn to tell the difference.

Get the echocardiogram and ask about anesthetic monitoring as described above. If you are still uncomfortable, self refer to a specialist in internal medicine. Find one on:
www.acvim.org

Good luck and please let us know how things go for your cat.

Sincerely,

Arnold L. Goldman DVM, MS
Med Help

4 Comments
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203342_tn?1328740807
Thank you! I will follow your suggestions. Thank you so much. I will let you know how she does. God bless,
April
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203342_tn?1328740807
I just realized you asked how the vet came up with that diagnosis (of the heart disease). My cat has been throwing up off and on for a long time now and has lost a lot of weight this year (4 pounds). When I took her to the vet a couple of weeks ago she noticed a heart murmur and did an ECG on her and it showed dips where there shouldn't have been. All of these symptoms leads her to think she has this Hypertrophic Cardiomyopathy.

I just talked with the specialist and it would be another $400 for him to do an echocardigram. I still have to save for the surgery to remove this lump and the medication we need. I've already spent several hundred dollars on her and we just don't have a lot more. I wish I could do all these tests but I can't afford much more. I will just have to do the best I can and hope for the best.
Thanks again for responding to my post. It was very helpful.
Sincerely,
April
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931217_tn?1283484935
Hi again,

Having not examined your cat personally, let me say that chronic intermittent vomiting (what your cat reportedly does) and weight loss are not specific findings for any particular body system, much less a particular diagnosis. In light of the demonstrated presence of a mass which cytology has confirmed is a sarcoma, the weight loss is likely due to that disease (cancer cells use and waste a lot of energy). It is also possible that the heart murmur is an incidental finding, in other words has no real significance, especially as compared to the other problems. Further, many cats with undiagnosed inflammatory bowel disease (IBD) (the cat form of "irritable bowel" are chronic intermittent vomiters. Vomiting is not a direct sign of heart disease. While some cats with heartworm or other heart diseases do vomit, they also have other signs such as enlarged heart, trouble breathing, weakness, cough, etc. Finally, interpretation of electrocardiograms varies with the reader. It is easy to overinterpret them, especially in a cat, as the variations in the tracings are tiny as compared to dogs.

You might consider simply having the specialist just examine the cat, with no commitment on your part to pursue further diagnostics. That way you get the help you need in prioritizing the cats problems. If the cat has significant heart disease, it may not be prudent to do any surgery at all. If he/she doesnt, then you need not spend money on further heart disease workup. My advice is to get the internist consult as a second opinion. The murmur may be a red herring or not even repeatable (may not be there at all any more). Plus, you get the advantage of a second opinion on the mass and the other issues.

In summary, spend now on a complete evaluation before rushing headlong to treatments. You may save money and also your cats quality of life. You can find a specialist (diplomate of the american college of veterinary internal medicine) at www.acvim.org

Good luck.

Dr G
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234713_tn?1283530259
Aleda M Cheng, D.V.M., C.V.ABlank
American Animal Hospital
Randolph, NJ
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