Castiel has a Surgical Consult

Once again, we handed over our little panther to a vet technician who carried him into the vet hospital. We were relegated to the parking lot  for the next hour and a half.  COVID regulations make what is already impossibly difficult worse. We understand the need to keep the medical staff safe and disease-free but separating us from Castiel at this time was so difficult. We wanted to be there to reassure him, to comfort him, to pat his little head. We wanted to see the doctors, see the facility, be reassured that he was in good hands. We wondered what was happening behind the curtain.

About an hour after handing him over to the technician, the surgeon called us. We put him on speaker phone so we could both hear. He wanted to know we were sure of what we were asking. He said, ” I can take it off but I can’t put it back on.”  We weren’t sure… we weren’t sure of anything. We wanted to scream that. I’m sure we sounded a complete mess. We tried to breathe.  We had a list of questions prepared ahead of time. We asked him about his experience with amputation. We asked about his experience with front leg amputation. Did he follow up with patients — how did they do? Did he think Castiel would adapt despite his age and tubbiness? He thought he would. He said it would be harder for Castiel with a front leg amputation because cats place most of their weight on the front. But he thought he would figure it out. He said he thought Castiel was otherwise healthy and that he would do okay during the surgery. He  described the pain medicines that he would give and how we could manage Castiel’s pain. He said he would help us to make sure Castiel was not in pain. The surgery sounded incredibly scary – the removal of the whole leg and the scapula. Why aren’t there good prosthetic options. Why doesn’t Science know how to kill the cancer and save his limb? Why didn’t we study oncology. We felt useless.

We know we shouldn’t ask the question but we had to — you know the question. We all ask it. “What would you do if it was your cat?” What he said gave us pause. He said he would wait… he might assume more risk and gamble that he could wait a little longer until the cancer started growing and then maybe remove the leg. We didn’t know what to think. Was it like the stock market — some people are comfortable with more risk where others are more risk averse or did he maybe think Castiel wasn’t a good candidate and didn’t want to say so directly. We asked for clarification. He said it was like the stock market. He would gamble a bit more — take on more risk for perhaps quality of life, or at least that is how we understood it.  But he also cautioned “that when the pathologist says the cancer will come back, in his experience, 99 percent of the time, it does.” He didn’t think removing the leg was the wrong thing to do. He left the decision with us. He explained that if the cancer spreads, it would shorten his life.  He said the recommendation for this kind of cancer was usually  to treat it with surgery, radiation, and chemotherapy. He said he wasn’t an oncologist so he couldn’t speak to what was best for a particular cancer. We understood also that he was a surgeon, confident in his skills, possibly able to detect changes earlier and easier than us in his cat, and perhaps this went into his decision-making tree in answering our question.

We were uncertain. It is easier to make a decision when everyone agrees on what is best but that wasn’t what we were hearing.  We had heard sometimes that vets try to get a feel for where the patient’s guardians want to go with treatment and then advise along those lines. We don’t know if this is true.  We felt like we had received an independent opinion and we were grateful for it, even if it gave us pause. We were reminded of a friend who shared her experience with amputating the leg of her cat to try and beat cancer. In her case, however, the cancer had unknowingly already spread to the lungs and her cat only survived a year and a half. She said she was “haunted” by the experience. She said her cat didn’t adapt well and that “he was never the same.”  We appreciated her honesty.  Perhaps her cat didn’t do well because the cancer had already spread at the time of amputation or perhaps her cat was depressed by the loss of the limb.  We can’t know, but we felt her pain and despair, and it was real and palatable — and it scared us.

A family member who had been a vet tech for several years said she wouldn’t do it. She said she had never seen a good outcome. She said she would let him live out his life as is and let him go. We were horrified.

We went back and forth…we read more journal articles. We read books about how fibrosarcomas are treated in humans (much of it sounded similar). Should we rely on science and the information from the veterinary and oncology professionals or should we listen to family and friends who advocated for quality of life (no amputation) or letting him go. We couldn’t give up on him so it was between palliative care and surgery (and possibly adjuvant radiation). We changed our minds a million times a day. Emotionally, I can’t imagine him without his beautiful black paw that I have kissed countless times. I had nightmares imagining seeing it separated from him lying on a table. It was too much to bear. I wished I was the kind of person who could do something with stress — exercise more, throw myself at my work, drink like a fish, whatever — but I’m not.  I just lie awake agonizing in the dark. I think we know that the science suggests that the best likelihood for prolonged life  is to do the surgery and follow it with radiation. But science deals in likelihoods and medicine is not an exact science and never will be.  There are too many variables — too many unknowns. This is the biggest decision we have ever had to make. What if we get it wrong? What if the naysayers are right? My husband tells me that we will know that we did our best. Is that enough? I don’t know.  He’s our baby panther and we love him so much. He just can’t be sick.

Here is Castiel as a baby. This is my husband holding him on the day we brought him home



A Consult with the Veterinary Oncologist and More Tests

The COVID has made receiving veterinary care so much more difficult. We  had to hand off Castiel to a technician who brought him into the SAGE Vet Hospital, while we waited in the car. All our contact with the doctors was through a telephone call.  We weren’t allowed to meet them in person – even masked.  How do you know if you can trust someone you can’t see.  Cancer is serious — life or death stuff — and we were talking to someone we couldn’t see – whose reactions we could not judge. It felt like an impossible situation. The oncologist did not inspire confidence. I’m sure she is probably well educated — much more than us — but she didn’t answer questions well on the phone.  She paused a lot. She sounded uncomfortable and as a result, we were uncomfortable. We didn’t know what to think, maybe if we could have seen her — but we couldn’t.

The medical oncologist conducted a CT scan (a CAT scan of our cat, ha ha!) and an ultrasound to try to determine if the cancer had spread. They didn’t see any signs of spread. However, the CT showed a cyst or lump in one of his thyroid glands. This might be cancer or it might not.  Malignant thyroid cysts in cats appear to be rare in the literature but in reality, we didn’t know. Fibrosarcomas are supposed to be 1 in 10,000 — we were already unlucky. Could we be unlucky again?  Worse, the oncologist didn’t mention this finding to us — a vet friend who we phoned one night out of the blue, probably breaking all protocols, pointed it out to us and recommended we check it.  Why hadn’t the oncologist mentioned it? We asked her… she didn’t think it was anything to worry about. It could be but maybe it wasn’t. Ugh! So much uncertainty! We didn’t want to remove his leg if the cancer had already spread but none of the tests claimed to be 100 percent. How could we make this decision? How could we even consider it… we could hardly bring ourselves to even say the word “amputation” never mind visualize it or consider doing it.

We saw our local vet to test the thyroid — it was normal. No hyperthyroidism. At 18.3 lbs he was still a big cat and well-groomed despite his now Frankenstein suture and funny haircut from all the tests and anesthesia monitoring.

The oncologist recommended we remove his left leg and scapula to give him the best chance of survival and a prolonged life. She said radiation and chemotherapy alone wouldn’t likely work. She thought the cancer would eventually spread, and that the cells on the edges might be more aggressive. She also recommended radiation and chemotherapy.

Our mostly retired veterinary friend (Castiel’s first doctor ) — the man we called out of the blue, offered to review the medical results and help us understand what it all meant. He has probably had more years as a practicing veterinarian than we’ve been  alive.  We wanted a second opinion from someone we trusted and who had no money in the game.  We trust our local vet but we didn’t know about these strangers at the vet hospital who we couldn’t see and whose reactions we couldn’t gauge over the phone.  Cancer treatment is expensive and while we believed everyone was telling us what they truly thought was best for Castiel, we weren’t sure. Family suggested vets were in the money making business, and this led to doubt.   And worse, family members voiced that we should do nothing and  “just let him go.” They told us we were being cruel. We felt like monsters.  Our vet friend helped calm us. He told us that he thought amputation was the best chance for a longer life. He assured us that he thought Castiel would adapt. He said he wasn’t sure if he would do radiation and that it would depend on if we got clean margins.  He said he didn’t think cats had the same psychological reaction as humans did to the loss of a limb. But how could we really know?  I think we were already grieving for Castiel’s affected limb. Our vet friend listened to us and we felt a little calmer. Another friend from church brought us a hot meal that night and a bag of groceries – easy to prepare things.  These things made the hard things a little easier.  People on this website reached out to us — they gave us tips and advice, they shared their stories, and they listened to our fears.  We were grateful and felt less alone.



Histopathology Results

The histopathology results were devastating.  The mass was taken from the mid proximal (upper) left humerus (front upper bone).  It was an oval mass measuring 2.5 cm in diameter. The dermis and subcutis were infiltrated by a “densely cellular pseudoencapsulated, moderately well-demarcated invasive neoplasm.”  Cancer. The report continued, “Neoplastic cells  are arranged in  interlacing bundles, streams, herringbone patterns, and occasional whorls, with moderate amounts of basophillic, wispy stroma and collagenous stroma.” These are indicative of a sarcoma.  “The neoplastic cells focally extend to one deep margin and abut the lateral surgical margin (separated from the surgical margin by only a few collagen fibers).” Bad news.  What all this was saying was that he had a malignant subcutaneous fibrosarcoma that was incompletely excised. The margins weren’t clean.  It was still there…growing, potentially spreading.

The tumor was classified as Grade II, intermediate.  Again, we felt so guilty for not catching it earlier. Why hadn’t we seen it? Felt it? The pathology report said that cats with a grade II soft tissue sarcoma “had a median survival time of 514 days,” but the pathologist cautioned that “the grading scheme had not yet been validated by other studies.” He wrote that “feline fibrosarcomas in general tend to be highly locally invasive, with a metastatic potential that is low initially but appears to increase over time.” He continued stating, “In this case, neoplastic cells extend to deep margins, and there is high concern for local reoccurrence.”  The report stated, that “aggressive surgical excision with wide margins appears to contribute to extended tumor-free interval and survival times in cats.” He recommended a consultation with a veterinary  oncologist to discuss possible adjunctive therapies.

The report also said that there was “no overt histologic evidence to suggest this may be an injection site sarcoma (no peripheral aggregates of adjuvant-containing macrophages, no lymphoid follicle formation, no numerous multinucleated giant cells or marked pleomorphism).”  The histopathology suggests it was a spontaneous fibrosarcoma. Bad luck.   We checked the veterinary inoculation records. There is no record of him having a vaccine in that location. We had never given him the FeLV shot as he is indoors only but he had received the rabies vaccine as required by California law but not in that location.  However, we adopted him at 6 mos. It is possible (likely) that he had vaccines prior to our adopting him.  It is also possible a vet technician might have mixed up a left and right leg or that Castiel was being difficult at shot time, so the technician gave it elsewhere and didn’t note it in the paperwork. So many unknowns. He was also found by the rescue at a Maritime Academy, so he may have been exposed to something there or from his mum.  Vaccine associated sarcomas have a worse prognosis than non-vaccine associated sarcomas, we’re told. We couldn’t be 100 percent sure which type it was, according to the vet. The vet said that it should be treated as though it was a vaccine induced sarcoma.

Every article I had been reading said the first surgery was the best chance to get all the tumor. We hadn’t gotten it.  Would this lead to cancer seeding –spreading? These kinds of cancers are very difficult to get — they send out tentacles and they aren’t visible to the naked eye.  Our vet had tried her very best but the monster was still there. And how long would it take to get an appointment with a veterinary oncologist? One place said they could see us in late December — too long.  We called SAGE, they could get us in next week. Everything was taking so long but the report did  say it was slow to metastasize so maybe there was hope but we worried, ” how long has it been there?”

The only encouraging news was that the X-rays looked clear and the blood work was mostly normal, only the globulin was slightly elevated. We made an appointment for Castiel with a veterinary oncologist and went home and collapsed.

Everything stopped. The wet laundry sat in the dryer growing mildew.  The dishes sat in the sink. No one made dinner.


Castiel’s First Surgery

Castiel underwent surgery at his local vet to remove the lump so that it could be tested to determine if it was benign or malignant. We remained hopeful…maybe we would get the entire lump and good margins and all would be well. We were hoping… and my husband was thinking this could happen but I knew that cancer sends out tendrils and I was worried. The fact that it had grown considerably in the last week was alarming. I had been reading everything I could on feline fibrosarcoma. I went nuts on Pubmed, I plowed through veterinary journals. But I was aware that all my Googling and reading wasn’t equal to a Veterinary degree and years of practice. I learned enough to ask some questions – enough to be scared.

Castiel did well in the surgery. Thankfully, he had no issues with the anesthesia and came out of it quickly. His surgical scar was enormous but the lump appeared to be gone.  We hoped it was gone.  Castiel spent the afternoon recovering at our vet’s office and came home that evening. She told us he might be groggy, that we shouldn’t let him jump or move around much, that he might not be hungry.  She put an Elizabethan cone on him. He fussed with the cone on the way home, plotting its removal.

When we arrived home, he flew out of the carrier like a bat out of hell and immediately shirked his way out of the collar and  gobbled down his sibling’s leftover supper. He  wasn’t interested in keeping still. We had to settle him down as he was making his suture bleed. We gently cleaned the suture and replaced his cloth cone. He sulked. He kept tripping over it when he walked and it made it hard to eat. We drove to the pet shop and bought an inflatable doughnut cone. He hated that one too. Back to the cloth cone.  He was still drugged so he wasn’t in pain — that happened at about 3 am. We gave him the pain medicine the vet prescribed  and he napped until breakfast time. Never one to miss a meal, he was up meowing as soon as the sun began to rise.

It took another three days to get the histopatholgy results.

I hate this cone too.

A vet visit to investigate the lump

We showed our vet the lump. She seemed calm… she always seems calm even when she is being bitten or covered in cat poo, as is usually the case with Castiel.  He always pees and poos when he is nervous — a real nightmare at vet visits. Our vet’s office takes these nervous movements in stride, even when he smells up the whole office so bad that we’re left gagging. No amount of fasting solves the problem, we’re convinced he saves up poo for car rides and vet visits.  We come prepared with pads and cat wipes. We often joke that we should get our vet a full raincoat that she can reserve for his visits. Our vet is super nice and gentle — and calm. And she was calm while she felt the lump.

She mentioned that lumps could be lots of things.  I think she was hoping it was something else too. We clung to that hope — even though, I didn’t think the result would be good. She did a Fine Needle Aspiration. She took X-rays of his leg and thoracic area (lungs). The X-rays didn’t show anything, just a little arthritis in that leg. We had to wait three days for the FNA. They were painstaking. We wanted it to be a lipoma or a cyst but it wasn’t rubbery and it didn’t hurt but still we wanted to believe it wasn’t malignant.

Three days later, we received a call from our vet with the results — it showed inflammatory cells and spindle cell proliferation.  The report said there was “concern for sarcoma” but more testing was needed.  The pathologist couldn’t say for certain. We clung to hope. Spindle cells don’t necessarily mean cancer — but they often do — they often mean some kind of sarcoma.

Our vet suggested we do a surgery to remove it. We scheduled the surgery for the first available date –early the following week. We wanted to test sooner but there were no appointments.  We debated if we should have the surgery at a specialty vet hospital but our vet was confident she could do the surgery. I wonder if maybe she thought it might be something else too. We still had hope it might be something else. In retrospect, we probably should have gone to the specialty hospital when we suspected sarcoma, but we didn’t know it was sarcoma and we were still in diagnostic mode.

In less than a week, the lump grew. Cancer means rapidly dividing cells. Benign things don’t grow that fast, I told myself.