Should I be going on a tumour hunt?

Re: Should I be going on a tumour hunt?

grumpyoldman — Sun, 28 Jun 2015 19:25:40 GMT

I have a nurse with a geriatric cat with renal problems , and ongoing hypercalcaemia which has been between 3-4 and 3.6 for 2 years .Weight stable etc I am not sure if the idiopathic hypercalcaemia is becoming more common or we are getting better at picking them up ?

Re: Should I be going on a tumour hunt?

Hannah Wynne Richards — Sun, 28 Jun 2015 11:16:59 GMT

It sounds as though you managed the case well.

Wynne

Re: Should I be going on a tumour hunt?

Thomas Johnson — Sun, 28 Jun 2015 10:16:27 GMT

[quote user="Thomas Johnson"]

Sorry for the delay with an update, I had a long chat with the owners and we've started the cat on low dose prednisolone, 1mg sid (0.32mg/kg), and will repeat bloods in a few weeks to re-check calcium levels.

[/quote]

There was no response to the prednisolone, we increased the dose and still no response, so at that point decided not to continue with any treatment or investigation for the hypercalcaemia. The cat continued on Fortekor, Kaminox and renal diet, with occasional lactulose for constipation. It managed well until last month when it had a uraemic crisis, there was little response to fluids and we decided on euthanasia.

Re: Should I be going on a tumour hunt?

Anthony Todd — Thu, 13 Nov 2014 16:05:53 GMT

[quote user="Thomas Johnson"]Except this cat has been quite happy eating just Royal Canin Renal Diet for the past two and a half years...[/quote]

"Sure have" says the cat "So I hope they don't change it, as I said before"

If it is idiopathic and azotaemic I would usually go for dietary change first (probably a calcium restricted diet, or a high fibre diet) and then would consider alendronate (a bisphosphanate) in preference to pred.

"When I read that", said the cat darkly "I thought to myself, "over my dead body", I'd rather starve; high fibre, yuk, not me"

Re: Should I be going on a tumour hunt?

Martin Atkinson — Thu, 13 Nov 2014 16:05:46 GMT

[quote user="Anthony Todd"]Speaking as the cat, "Yippee, phew thank goodness, I hate all the palaver of these "tests" which seem to delight the vet,cost my owner a load of dosh and don't make me feel any better at all, not that I feel that bad........"[/quote]Speaking as the cat I eluded to in a previous post he said, 'Thank goodness my vet recommended this treatment and my owner agreed. I feel so much better, my appetite has actually increased with the medication and I feel strong enough again to annoy that pesky other cat we have at home and play with the new kitten we have. I love my weekly visit to the vets for my chemotherapy because it doesn't hurt and I get lots of fuss and cuddles from the nurses and a new toy each time'.

And speaking from the grave he said' 'I think that extra 9 months of quality life was well worthwhile but I'm glad my vet recognised when I'd had enough and let me go to the happy mousing ground in the sky. But I wish humans wouldn't indulge in so much bloody anthropomorphism'.

Re: Should I be going on a tumour hunt?

Thomas Johnson — Thu, 13 Nov 2014 15:29:20 GMT

[quote user="Anthony Todd"]

" I just hope they don't decide to change my diet . I only like what I'm having, and have had for 10 years [plus the odd prawn and a bit of roast duck] and I'm not going to change now, no matter how long they starve me"

"I'll guarantee the new diet will be awful and I'll die eventually anyway so at least I can go having had nice food"

[/quote]

Except this cat has been quite happy eating just Royal Canin Renal Diet for the past two and a half years...

Re: Should I be going on a tumour hunt?

Anthony Todd — Thu, 13 Nov 2014 14:54:22 GMT

[quote user="Christopher Saul"]BUT That said, it depends to some extent upon how far the owners wish to take it. If you and the owners decide ( as is likely with the age of the cat) that chemotherapy or surgery are not appropriate for the cat in light of its age and underlying heath, there seems little point in subjecting the cat to extensive investigations.[/quote]

Speaking as the cat, "Yippee, phew thank goodness, I hate all the palaver of these "tests" which seem to delight the vet,cost my owner a load of dosh and don't make me feel any better at all, not that I feel that bad"

"I'll guarantee the new diet will be awful and I'll die eventually anyway so at least I can go having had nice food"

Re: Should I be going on a tumour hunt?

Thomas Johnson — Thu, 13 Nov 2014 10:11:39 GMT

Re: Should I be going on a tumour hunt?

Christopher Saul — Fri, 24 Oct 2014 19:22:05 GMT

I'd echo Andy's thoughts that this seems on the face of it to be either idiopathic hypercalcaemia or a paraneoplastic syndrome; with renal disease you tend not to get an ionised hypercalcaemia. Therefore, the textbook answer (not necessarily the common sense answer) to the original post would be yes, a tumour hunt is the next step

BUT That said, it depends to some extent upon how far the owners wish to take it. If you and the owners decide ( as is likely with the age of the cat) that chemotherapy or surgery are not appropriate for the cat in light of its age and underlying heath, there seems little point in subjecting the cat to extensive investigations.

However that is not to say you should ignore the hypercalcaemia; it can lead to various deleterious effects such as constipation and of course can hasten the demise of the kidneys as well.

So perhaps in this case, assuming the hypercalcaemia is persistent, it might be time to break out the old adage "don't let anything die for want of steroids". Good old pred.

I would though, as Andy suggests, run vitamin D metabolites. At a recent SAMSoc meeting there was case presentation about hypercalcaemia due to hypervitaminosis D from a commercially available diet.....

Re: Should I be going on a tumour hunt?

Andrew Kent — Fri, 24 Oct 2014 16:22:40 GMT

[quote user="Gerry Polton"]I might have missed a critical detail here but isn't chronic renal disease one of the most common underlying causes for hypercalcaemia in cats? [/quote]

Hypercalcaemia is common in renal failure but most often this is a high total calcium with normal ionised calcium, hypothesised to be due to binding of calcium to retained anions. So with an ionised hypercalcaemia it is more likely that a primary calcium disorder is present. Though as always not every cat reads the rule book!

[quote user="Thomas Johnson"]I thought that if the hypercalcaemia was due to renal disease the cat ought to have a high PTH?[/quote]

Exactly - if the mechanism of the hypercalcaemia is renal then the expectation is that this should be driven by PTH and so a low level is not consistent with this. Some cats will have a normal PTH with renal disease but in this case it is below the limit of detection of the assay.

Andy

Re: Should I be going on a tumour hunt?

Thomas Johnson — Fri, 24 Oct 2014 15:39:15 GMT

[quote user="Gerry Polton"]

I might have missed a critical detail here but isn't chronic renal disease one of the most common underlying causes for hypercalcaemia in cats? In my opinion, you have a satisfactory diagnosis already. I do accept that just because a known underlying cause and a known consequence are present at the same time this does not constitute proof of causality but judgement must be exercised in these cases. I echo the previous comments that further investigation also seems inappropriate on age and prognosis grounds.

[/quote]

I thought that if the hypercalcaemia was due to renal disease the cat ought to have a high PTH?

Re: Should I be going on a tumour hunt?

Martin Atkinson — Fri, 24 Oct 2014 15:10:13 GMT

[quote user="Sammy82"]But what are you gonna do if you should find a tumour, put a 16 year old cat through surgery/chemotherapy? [/quote] I recently had a mildly azotaemic 20 year old cat with intestinal lymphoma on which I performed an enterectomy and chemo and he lived for another 9 months. The cat had good quality of life and the owner was delighted.

Re the OP: I find this is a very common scenario and it is usually idiopathic or secondary renal hyperparathroidism. This level of hypercalcaemia seems to cause no problems in old cats. I would have a good grope around for lumps but the most invasive I would go is a chest X-ray.

PS the cat eluded to above was not hypercalcaemic, but the same owner's other cat of similar vintage with stage 2 IRIS CKD is, with no evidence of tumours.

Re: Should I be going on a tumour hunt?

Gerry Polton — Fri, 24 Oct 2014 14:52:21 GMT

Gerry

Re: Should I be going on a tumour hunt?

Thomas Johnson — Fri, 24 Oct 2014 14:45:21 GMT

[quote user="Sammy82"]

But what are you gonna do if you should find a tumour, put a 16 year old cat through surgery/chemotherapy? Obviously you have to discuss this with the owner. Spending all the money and stressing the cat with further investigations if they then don't want invasive treatment is neither fair on the cat nor their wallet. In the end it is the owner's decision how far they want to go, but if it was my cat I wouldn't take it further.

[/quote]

My thoughts exactly, I've discussed with the owner that I don't think further diagnostics are necessarily in the cat's best interests, but that we might consider doing something to try and reduce the calcium levels. The owners are realistic, but want to be sure they are doing the right thing. I just wanted to get a feel for other people's opinions, and whether there was anything I'd missed.

Re: Should I be going on a tumour hunt?

Sammy82 — Fri, 24 Oct 2014 13:49:42 GMT

Re: Should I be going on a tumour hunt?

Andrew Kent — Fri, 24 Oct 2014 13:38:41 GMT

Hi Thomas,

You could also measure the PTHrp and Vitamin D metabolites (endogenous & exogenous) on blood before anything else. He may well be an idiopathic hypercalcaemic if all of these are normal, though imaging could still be argued to be useful to definitively exclude a neoplastic cause.

If it is idiopathic and azotaemic I would usually go for dietary change first (probably a calcium restricted diet, or a high fibre diet) and then would consider alendronate (a bisphosphanate) in preference to pred.

I would tend to try to control it as otherwise it is likely to lead to a more rapid progression of renal disease (it may have even come before the renal disease - has it ever been azotaemic and not hypercalcaemic?)

Andy

Re: Should I be going on a tumour hunt?

Hannah Wynne Richards — Fri, 24 Oct 2014 13:15:04 GMT

First do no harm.

Given his kidney parameters, his age, and the fact that the tumour is non-palpable and non-symptomatic, I would say will, if left well alonewill die with cancer, not fromcancer - and over-enthusiastic diagnostics could hasten his end.

Wynne