|This Web page was developed in the hope that it will help other cat caregivers faced with feline liver cancer. Both my wife and I learned much from the diagnosis, treatment, hospice, and ultimate return to God of our cat V, who died on 7 March 2005 from hepatic neoplasia, a rare, diffuse form of feline liver cancer. We wanted to share this knowledge with others whose cats may experience a similar illness. We faced many challenges and difficult decisions during this experience. We hope by sharing how we addressed these issues that our experience may help others.
This page is assembled primarily as a chronology of events from the time V became ill until her death. I address the various challenges and decisions we faced as they occurred, sharing our thought process, learning, and the techniques we developed to address these issues.
As I am not a veterinarian, the information in this page should be not be construed as veterinary medical advice. Consult your cat's veterinarian for all medical advice.
V was a wonderful cat. After testing to assure she was not carrying FIP (Feline Infectious Peritonitis), FIV (Feline Immunodeficiency Virus, i.e. Feline AIDS), or FeLV (Feline Leukemia Virus), she was introduced to our other three cats at that time: Stimpy, Lydia, and Koosh. V immediately became a member of Stimpy's "harem." Later, when Kenny joined our family, he showed particular fondness for V. Tyler Bear, the latest addition to our family, was not V's favorite: apparently, he could never understand her lack of a tail and she tired of him constantly trying to find it. However, peace generally reigned in our multi-cat home.
V had always been healthy and had always received the best medical care that money could buy. While our cats live indoors, she like the others received regular inoculations including FIP boosters, scheduled exams, and an annual dental cleaning.
V was prissy and fastidious, a perfect lady who cleaned herself with deliberate precision. If you touched a spot she had just cleaned, she would return a disapproving look, then proceed to again meticulously clean the spot to her satisfaction. When playing alone, she would stop the moment she found us watching her, as if her spirited play would be seen as unladylike. V loved to play with us, especially practicing her hunting skills on an old necktie. She also loved to be brushed and we were always amazed at how much fur she would shed during her daily brushing sessions.
V was also extremely affectionate. As I work from home, she was a regular companion, sleeping in a small cat bed in my office. When V wanted attention, she'd let you know in no uncertain terms: she'd rub against you and meow repeatedly until she was rubbed or brushed. V's favorite trick was to watch you in the shower, then immediately demand attention as you exited. V was "she who must be obeyed" among our six cats and earned the nickname "Demand-o kitty." V also believed that as soon as any bathroom faucet was turned off, this meant it was time for her parents to brush her or play with her. Needless to say, one had to add time to their morning routine in order to attend to V's demands.
As with all our cats, V slept with us. Her favorite position was curled up next to my wife's head. She would sometimes crawl onto my chest or by my side, seeking attention in the middle of the night. If her demands were not met, she'd mark the lampshade on my night-stand, banging the shade into the window blinds until I acquiesced. Once satisfied, she'd sometimes curl up in my lap to sleep or return to her place next to my wife. We would not have it any other way.
V enjoyed watching television with us, and would sit on a pillow between us on the living room couch, or on the back of the couch, watching along with us. Near the end of her life her favorite movie was Finding Nemo. She liked it so much we bought her the DVD.
Please visit V's Album for more photographs of our beloved little V.
V's illness and diagnosis
Initial symptoms and diagnosis
In January 2005, we noticed that V was losing weight and began vomiting. We took her to our veterinarian, Dr. Patricia Hague, DVM, of the Cat Hospital of Las Colinas, for evaluation. Dr. Hague performed a full blood profile which revealed V's liver functions were abnormal. V was also X-rayed, which showed her liver was somewhat enlarged. The X-ray also ruled out the presence of gall stones which, while somewhat rare in cats, could cause similar symptoms.
As Dr. Hague informed us, and as subsequent research into the subject has shown, there are four major categories of liver disease in cats:
V's symptoms, blood test, and X-rays did not support a diagnosis of FLS. Cancer in cats does not generally develop until age 10 or later. As V, by our estimate, was roughly 8.75 to 9.25 years old, this made cancer less likely, but it could not be ruled out.
We decided to initially treat V with a combination of steroids (Prednisolone) and antibiotics (Amoxicyllin). However, Dr. Hague noted, and our research has shown, that only a liver biopsy could provide a definitive diagnosis. Since V was clearly ill but not in immediate danger her hydration, behavior, and other vital signs supported this beginning with medication was a prudent and conservative course of action. If medication did not work after a reasonable period of time, we would proceed with a biopsy.
In an attempt to stem V's weight loss while on medication, we offered her a variety of foods, with mixed success, the objective being that anything she would eat was good, just as long as she ate. We also had Dr. Hague administer weekly B-12 shots to stimulate her appetite, which also appeared to work for a couple of days after each injection.
The most challenging aspect of this phase was medicating V. Some cats take pills or liquid medications with ease. Such was not the case with V. We had learned how to medicate our cats from our vet, supplemented with a review of June Campbell's article "Don't Be a Pill!" in the May 2000 issue of Catnip. An excellent online guide to medicating cats is "Giving Oral Medications to a Cat" from the Washington State University College of Veterinary Medicine.
We tried both liquid preparations and pills for V's medication and found, in her case, pills were more easily administered.
A brilliant idea was developed by my wife: to make it easier to give pills to V, she obtained empty gelatin pill capsules from a local pharmacy. These are similar to the kind of capsules one finds in human medications, such as antihistamines. Putting small pills in one of the capsules made for a better grip when administering the medication. Larger pills could be cut in half for insertion into the capsules. Using capsules had no effect on the medication as the capsule would dissolve quickly once swallowed, allowing the medicine to then dissolve.
Medication proves unsuccessful
After five weeks of treatment with these medications, V failed to improve despite encouraging signs:
Since drug therapy was not working, Dr. Hague recommended we take V to the Animal Diagnostic Clinic of Dallas (ADC) for a definitive diagnosis via biopsy. We agreed and Dr. Hague sent V's medical records to ADC.
Ultrasound, surgical biopsy, and feeding tube placement
On 22 February 2005, Dr. Caeley Melmed, DVM, V's veterinarian at ADC, examined V thoroughly and reviewed with us the possible causes for her liver disease, diagnostic options, and associated risks. We began with a basic ultrasound examination. The ultrasound revealed abnormalities that could not be seen in the earlier X-rays. A fine-needle aspiration also revealed the presence of abnormal cells. A biopsy was recommended, with the option to install a feeding tube to provide V with nutritional support.
V was also tested again for FeLV and FIV, both of which proved negative. FeLV is a common cause of cancer in cats.
Our choices regarding the biopsy were to perform either an ultrasound-guided needle biopsy or a surgical biopsy. Given that no large mass of abnormality appeared to be present, such as a single or "focal" tumor, a surgical biopsy was deemed to be the best course of action. We struggled somewhat with this decision, since a surgical biopsy was a more invasive procedure. However, our decision came down to the facts that:
On 24 February V underwent a successful surgical biopsy and placement of a feeding tube in her stomach. Dr. Melmed telephoned us after the surgery to inform us of the successful surgery, but that she was very concerned about V's prognosis. Dr. Melmed stated that neither she nor the surgeon Dr. Nancy Zimmerman-Pope, DVM, MS of the Dallas Veterinary Surgical Center (DVSC) collocated with ADC had ever seen a cat whose liver looked as abnormal as V's. Dr. Melmed was also surprised at how good V looked given how abnormal her liver appeared. We agreed to have the pathology work on V's biopsy samples analyzed "stat" so that we would have the results ASAP.
We were able to see V during visiting hours at the ADC on Friday 25 February and again on Saturday 26 February. Due to her condition, V was being treated in the Intensive Care Unit (ICU) at ADC, where she would remain for nearly five full days to assure her feeding tube was functioning properly and there were no complications from it or the surgery.
The ICU staff would bring V to an exam room where we were able to spend nearly two hours with her at each of these visits. We were fortunate in that not many visits had been scheduled, freeing most of the exam rooms: a normal visit lasts ten minutes to maximize the number of pet owners who can visit their pets with a limited number of exam rooms. Given how many pets ADC had in hospital, I was surprised by how few pet owners had scheduled visits with their sick companions.
We noted that the ADC staff used baby's blankets to keep their cats warm. We purchased some of these at our local Wal-Mart for use when V returned home.
On the night of the 26th, Dr. Melmed called to inform us that the pathology report had arrived. Unfortunately, the diagnosis was that V was suffering from terminal liver cancer, a diffuse neoplasia throughout her liver. Diffuse cancers, as opposed to focal tumors, cannot be treated by surgery or chemotherapy. While this news was not unexpected, it was devastating to hear. V's cancer was also especially rare since no other tumor could be found in adjacent organs. Dr. Melmed estimated that V might live anywhere from a few days to a week, two weeks at most.
Our Internet-based research on feline liver cancer showed that if V had a focal tumor, it might have been possible to remove this surgically and then begin a course of chemotherapy. According to one article, "Up to 70 percent of the liver can be removed without significant loss of liver function." However, the prognosis even in such cases is not good, with life expectancy thereafter in the range of 80-300 days.
On Sunday 27 February, Dr. Erika Pickens, DVM, of ADC called to give us an update on V's condition. Dr. Pickens was the attending veterinarian covering the ICU that day. Given V's poor prognosis, at my request Dr. Pickens generously arranged for us to have some time with V even though there were no formal visiting hours on Sunday. During our visit, Chris, a member of the ICU staff, instructed us on how to feed V using the feeding tube.
On the afternoon of Monday 28 February we brought V home from the hospital for hospice care. We felt that any time she had left was best spent with us at home.
Knowing when to stop
As V's condition was terminal, we developed specific criteria to guide us in determining if the end was near and if V should be put to sleep. While we wanted to spend as much time as possible with her, we wanted to assure that she was enjoying the best possible quality of life given her illness. The conditions we developed were as follows:
Despite her liver disease, V had only initially exhibited some jaundice in her mouth, which abated shortly after her initial treatment with medication. Her skin now exposed on her belly, left side, left-rear leg, and left-front leg as a result of the ultrasound, surgical procedures, and the placement of both an IV and the feeding tube remained pink and white, exhibiting no signs of jaundice.
We were also assured that V's cancer was not causing her pain, rather a general feeling of illness akin to what a human with the flu might experience. Nonetheless, we regularly monitored V's vital signs to assure she was not hiding pain from us.
Preparing to bring V home
Before bringing V home, Dr. Melmed and Amber, another member of the ADC staff, reviewed V's feeding tube instructions and answered myriad questions I posed to them on this and related matters. They also equipped us with a case of Hills k/d formula Prescription Diet® food to prepare for V and to be fed via her feeding tube. While Hill's l/d formula Prescription Diet might normally be prescribed for cats with liver disease, it was judged that, with V's specific condition, k/d would be a better match due to its lower protein content.
Additionally, Reglan® (Metoclopramide) was prescribed to prevent nausea and to promote peristalsis.
ADC also equipped us with several plastic, reusable syringes for use with the feeding tube. These were 25cc and 35cc Monoject®-brand syringes with a Regular Luer Slip connection that mated to the feeding tube. It helps to have a variety of such syringes in delivering medication or water via a feeding tube. We also obtained Monoject Regular Luer Slip syringes in 3cc, 6cc, and 10cc sizes. Having two or more of each size is helpful. The syringes were hand washed after administering food, water, or medication.
The Monoject brand is manufactured by Kendall, a division of Tyco Healthcare. Your veterinarian should be able to supply you with a range of syringes in different sizes to match the feeding tube.
We also prepared our home for V's hospice. Our primary concerns were assuring that she would not crawl into an inaccessible area and that her feeding tube could not get snagged.
We decided to close off the master bedroom to prevent V from crawling under our bed, a favorite hiding place. Since V would be hospiced in our guest room, we also "safed" the futon which doubled as both a couch and a bed by stuffing towels under it to prevent V from crawling beneath. We also moved furnishings to the master bedroom that might snag her feeding tube. While cats with a feeding tube wear a little elastic vest that keeps the tube close to their bodies, we did not want to take any chances.
We further committed to keeping V under 24-hour observation. During the day, this was easily done by me as I work from home. I put all business aside to attend to V. In the evenings, my wife and I watched V together or took turns. Overnight, my wife slept with V in the guest room.
We also kept a chart on V, similar to a medical chart, noting the times at which:
The cliché "pencil and paper never forget" holds true: we found keeping this chart to be invaluable.
We developed a system for preparing and storing the food along the lines provided by Dr. Melmed and her staff. The correct consistency was obtained by mixing one can of food with a tiny bit more than one-half can of water, e.g. 60 percent of the volume of the can, blending at high speed for one minute, stirring, then blending again at high speed for another minute. The resulting mixture was then strained to remove larger particles that might clog the feeding tube. We prepared a new batch of food daily, regardless of how much V had consumed the previous day. By preparing the food 10 minutes before her first feeding, it would be at room temperature, the temperature at which all cat food and water should be served.
The balance of the food was refrigerated in a standard covered plastic food storage bowl, specifically a Rubbermaid® 14oz (400mL) Servin' Saver with a Number 1 lid. By experimenting with our largest microwave oven, we found we could bring the refrigerated food to room temperature by microwaving at approximately 12 percent power for roughly 35 seconds. Temperature was then tested manually.
To heat the food, we placed a bit more than the portion of food to be fed into a small glass bowl for heating, as opposed to reheating all of the refrigerated food. We also found that using measuring spoons to scoop refrigerated food from the plastic storage container into the glass bowl for heating worked best for measuring the amount of food to heat.
As V was to receive at most 35cc of food per feeding, and a measured tablespoon is 15cc, we could closely approximate the amount of food to heat. This proved easier than trying to draw up the amount of cold food from the storage container into the plastic syringe used for feeding, transferring this to a glass bowl for heating, and then drawing up the heated food. By measuring and heating roughly 40cc of food in a small glass bowl, we were easily able to draw up the correct amount into the feeding syringe without introducing air bubbles into the mixture. Tilting the glass bowl while drawing the food into the feeding syringe aided in assuring a smooth mixture that was free of bubbles.
Feeding and medication
The exact, step-by-step procedures used to feed a cat via a feeding tube vary somewhat by veterinarian, by the size and condition of the cat, and the type of feeding tube installed. If the feeding tube is installed surgically, the cat will remain at the veterinarian's office for two days or more to assure the tube is working properly and that there are no complications.
The feeding procedure we used was based on that initially recommended by Dr. Melmed, then modified slightly through further consultation with her based on our experience. You should use the procedure specified by your veterinarian. For V, the procedure was as follows:
Since administering medication, food, and water the latter both before and after feeding can mean having three or more syringes to hold, we found simply placing the filled syringes upright in a wide-mouth drinking glass or coffee cup when ready for use worked well instead of attempting to hold or juggle all three during the feeding.
On Tuesday 29 February, Dr. Melmed telephoned to inform us that the results of culturing V's liver biopsy samples also revealed she had a serious pseudomonas infection in her liver in addition to her cancer. In questioning the origins of this infection, it appears that pseudomonas is a common environmental bacteria that is highly opportunistic. Healthy people and animals have been found to have small amounts of this bacteria present in their bodies or on their skin at any time, with which the immune system can readily cope. In a seriously ill animal, such as V, these bacteria can thrive. Ciprofloxacin was prescribed, with 1cc to be administered twice daily. We combined this with her feedings, administering the Ciprofloxacin in the middle of every-other feeding.
During the period from Monday 28 February through Friday 4 March, V's quality of life appeared good. Her respiration and pulse were normal, she made it to, and used, her potty box on her own, and her stools were solid. She also walked about the house on a few occasions, visiting favorite spots. She was generally alert, albeit the Reglan had a mildly sedative effect. She spent most of her time in our guest room and enjoyed watching the birds that fed on bird seed we had placed outside this room's windows.
The only thing we noticed that gave us concern was that she neither vocalized nor purred. Normally, V was talkative and purred readily. She tolerated her feedings via the feeding tube, but continued to refuse or ignore other food that was available to her. We knew she was on borrowed time, and every minute with her was a blessing. We also noted a marked, albeit brief, improvement in her within 24 hours after starting the Ciprofloxacin.
On Saturday 5 March, V's stomach contents measured over 10cc for two potential feedings that we then skipped according to instructions. We became concerned that her system was no longer digesting her food. V then vomited once, despite not having been fed for nearly 12 hours.
Unable to reach Dr. Melmed or the ADC due to the weekend, we were able to contact Dr. Hague who recommended the following modified feeding procedure:
V tolerated this new procedure well, but we noticed that her skin, which had remained pink and white, was now beginning to show signs of jaundice. Her jaundice deepened and spread during Sunday 6 March. By mid-afternoon Sunday, it appeared clear V's liver was failing. While her pulse and respiration remained normal, she seemed increasingly tired. While she still made it to her potty box, she did not have the energy to make it back to her bed. Always a little lady to the end, V never had an accident.
It was clear to us that V's battle was nearing its end and it was time to return her to God before her condition deteriorated further.
V returns to God
I contacted Dr. Hague's office when they opened at 7:30 on Monday 7 March, making an appointment to bring V in at 9:40. I put her carrier in the car in the event we needed it, but we had already decided that my wife would hold her on the ride to the vet. V always disliked the car, especially being in a carrier.
V had been favoring a certain pillow to lay upon. We wrapped her in a baby's blanket, placed her on the pillow, and I carried her to the car atop the pillow. My wife held V in her lap, covered in a second baby's blanket. V was quiet throughout the ride, taking in the scenery. She meowed three times when we arrived at Dr. Hague's office, the first sounds she had made since coming home from the hospital other than the one time she hissed at Tyler Bear when he got too close to her.
Dr. Hague examined V and assured us we had not waited too long, but that V was now very tired. We all went to the operating theater. I carried V on her pillow into the operating theater where she meowed again. Dr. Hague and her assistant administered some anesthesia gas to V. We had arranged this earlier as I did not want V to know what would happen. V drifted into sleep.
I was glad I had requested the gas for V as her veins and arteries were fragile. Dr. Hague gently shaved her right leg to find a site for the injection since the veins in her left leg, where her IV had been, were far too fragile and could not hold the needle. V left us quietly and uneventfully immediately after receiving the injection at 10:00.
Dr. Hague offered us the clippings from shaving V's leg, which we dearly wanted, and presented them to us in a small, beautifully decorated heart-shaped stone box. Dr. Hague gently put V's tongue back in her mouth as it had poked out as is normal from the gas.
My wife and I cried for a long time in one of the examining rooms, and then went for a walk while they removed V's feeding tube and surgical sutures. Dr. Hague presented V in a sealed box, telling us she was in a sleeping position. We thanked them for taking such good care of V, cried, and hugged. My wife and I had cried every day since hearing the results of V's initial ultrasound exam, and it seemed that just when one thought one had run out of tears, more would come.
Dr. Hague also presented us with two brochures: one on coping with our own grief, and a second on helping our other cats cope with their loss. Both have proved valuable.
Once we had learned V's condition was terminal, I began investigating firms for cremating her after her passing. We had gathered recommendations for crematories from both Dr. Hague and the ADC. After considering a variety of factors, we selected All Paws Go To Heaven (henceforth, "All Paws") to perform V's cremation. Our choice was based on recommendations, proximity to the Cat Hospital of Las Colinas where V would be put to sleep, and All Paws ability to schedule a private, witnessed cremation shortly after V's passing.
We had decided upon a witnessed cremation since we wanted to assure V's remains were handled with the utmost respect and that her ashes were returned to us. We wanted to avoid horror stories we had read and heard about, such as those experienced by customers of Pet Rest Crematory.
We drove to All Paws and met with Mike, the owner. After reviewing our desires and completing some paperwork, Mike escorted us to the back of the building where the crematories reside. I opened the box to find V wrapped in her blanket, on her pillow. We took her out and it looked like she was resting, her eyes open as they had been after her death and as was normal. She was still warm and supple. Mike took two impressions of her left-rear paw in damp clay that would be fired for us as keepsakes. My wife and I then kissed and stroked V one last time and she was placed in the crematory in her blanket with two of her favorite toys: an old necktie of mine she loved to chase and a small catnip fish with which she liked to wrestle. The crematory was closed and started. Mike left us to be alone until we were ready to depart.
We decided not to witness the last stages of the cremation, where V's cremains would be removed from the crematory and processed to a uniform size. I trusted Mike for the rest and, as V was cremated alone, I knew we would get her back. We returned at 14:00 to pick up V's cremains. I was surprised to see the small amount of cremains result from cremation. Mike placed her cremains in an acid-free plastic bag for us, then put this in a velvet scatter bag as we had said we wanted to find a special urn just for her that would speak to us, which Mike understood.
We are depressed and heartbroken, but also know that we did everything possible for V and she fought a brave fight. She had a good life, albeit shorter than we had ever hoped. We were so blessed to have had her in our life, and thankful that we had a last week with her after coming home from the hospital and before she was returned to God.
After the loss of a pet, one cannot help wondering if they did everything right or did they do enough.
Both Dr. Hague and Dr. Melmed have assured us that we did everything correctly and took all measures that were humanly possible in a timely manner to help V. We believe this, not only based on the assurances of V's veterinarians, but also from our research into V's illness and the range of treatment options available.
We owe our deepest thanks to
for their loving and expert care of V during her illness and for their superb support for us.
Should a biopsy have been performed sooner?
This was the first question I asked myself after learning V's diagnosis. I know that having the answer an exact diagnosis sooner rather than later would neither have changed the outcome nor affected V's quality of life.
I also know now, based on our research and the advice of our veterinarians, that the feline liver is essentially a "black box." Blood tests and X-rays will provide some indications, but it is nearly impossible to differentiate between the common feline liver diseases, with the possible exception of FLS, especially if X-rays fail to reveal gross abnormalities. Biopsy, specifically surgical biopsy, is the "gold standard" for accurately diagnosing virtually all feline liver disorders.
V's symptoms, her age, and her history of good health made cancer initially appear to be a low probability, but Dr. Hague raised the potential of cancer right from the start and made it clear that only a biopsy could provide a definitive diagnosis. As V's X-rays showed no focal tumors or readily recognizable abnormalities, with the exception of slight liver enlargement, medication was a prudent and conservative first course of treatment. It was our decision, i.e. that of my wife and I, to delay a biopsy to see what medication could achieve. As soon as we saw that medication was not working, we immediately initiated to more advanced diagnostics.
Accordingly, my wife and I are satisfied with our decision to delay a biopsy until after several weeks of medication proved ineffective. It would not have changed the outcome: V's cancer was rare, aggressive, and would not have responded to other forms of treatment. V's quality of life remained good throughout her illness until the very end, a testament to her great strength. However, if faced with this decision again, I would probably opt for an ultrasound examination as soon as the liver disease was identified so that the appropriate form of additional diagnostic tests, including biopsy, could be determined.
Cost of diagnosis and treatment
Anyone facing a diagnosis of feline liver disease should brace themselves as diagnosis and treatment are expensive.
We knew in advance that all forms of feline liver disease are expensive to diagnose and treat. Furthermore, treatment requires complete dedication on the part of the caregiver. In Beverly Ford's article "The Ways to Beat Liver Disease" in the February 1999 issue of Catnip, she states "Expect the cost of treatment to be expensive. Diagnosis alone can run up to $500, and full veterinary treatment can top $2,000."
We spent approximately US$4,000.00 from the time we first suspected V was ill through her cremation, 83 percent of which was spent with ADC and DVSC. For us, it was money well spent.
Veterinary research suggestions
While there has been extensive research into feline liver disease, there are two areas for additional research we believe could prove promising:
Resources and additional references