Pleural effusion cat case to discuss

RE: Pleural effusion cat case to discuss

Matt Hilary — Tue, 20 Dec 2016 19:03:58 GMT

Difficult to distinguish between reactive mesothelial cells (especially in potentially chronic effusion such as CHF) and carcinoma, though lymphoma should presumably be a more confident diagnosis

[quote]

OK I didn't spot the fact that the NT-proBNP was taken on pleural fluid. I'm not sure how this would effect interpretation of the result but if it was measured from a blood sample I'd be 100% confident in it.[/quote]

Differentiation of Cardiac from Noncardiac Pleural Effusions in Cats using Second-Generation Quantitative and Point-of-Care NT-proBNP Measurements

J Vet Intern Med 2016;30:536–542

The second-generation ELISA differentiated cardiac from noncardiac pleural effusion with good diagnostic accuracy (plasma: sensitivity, 95.2%, specificity, 82.4%; pleural fluid: sensitivity, 100%, specificity, 76.5%). NT-proBNP concentrations were greater in pleural fluid (719 pmol/L (134–1500)) than plasma (678 pmol/L (61–1500),P=0.003), resulting in
different cut-off values depending on the sample type. The POC test had good sensitivity (95.2%) and specificity (87.5%)
when using plasma samples. In pleural fluid samples, the POC test had good sensitivity (100%) but low specificity (64.7%).
Diagnostic accuracy was similar between first- and second-generation ELISA assays.

RE: Pleural effusion cat case to discuss

Martin Atkinson — Tue, 20 Dec 2016 15:05:32 GMT

[quote user="Sarah Keir"]I would speak to the pathologist who originally looked at the sample and get a feeling for how certain their diagnosis is. Mesothelial cells often look strange and reactive.[/quote]At least there is someone else who may have spotted the gorilla on the stage here.

RE: Pleural effusion cat case to discuss

Sarah Keir — Tue, 20 Dec 2016 15:02:14 GMT

I would speak to the pathologist who originally looked at the sample and get a feeling for how certain their diagnosis is. Mesothelial cells often look strange and reactive. See page 344 of BSAVA Manual of Canine and Feline Clinical Pathology (2nd edition); ' Mesothelial cells can be problematic to evaluate due to their propensity to exhibit cytological criteria of malignancy in response to any inflammatory process.' Even the actual pleural fluid is inflammatory to the mesothelium

RE: Pleural effusion cat case to discuss

Martin Atkinson — Mon, 19 Dec 2016 10:16:31 GMT

[quote user="Virginia Campbell"]

Why?

[/quote]Because the cytology is open to interpretation and nothing noted yet on imaging. I'm not saying its not neoplastic just be wary of drastic decisions based on that alone.

[quote user="Beats"]Lab results now received on submitted pleural fluid:
CARDIOPET PROBNP (FLUID) >1500.0 pmol/L[/quote]OK I didn't spot the fact that the NT-proBNP was taken on pleural fluid. I'm not sure how this would effect interpretation of the result but if it was measured from a blood sample I'd be 100% confident in it. I would trust that above interpretation of echocardiogaphy by a non-specialist. I have had a case where the echo performed by a cardiologist at the RVC who said it was normal but on the basis of a raised NT-proBNP I asked them to look again and on second viewing they decided the left ventricle was thickened and there was an outflow obstruction.

[quote user="Virginia Campbell"]

[quote user="Martin Atkinson"]Add pimobendan and benazepril to the frusemide and it will probably work wonders.[/quote]

That is 5 pills the cat has to take per day.

[/quote]I hadn't spotted that the cat has been put on ACEi but as said regardless of whether this cat has neoplasia or not I would be treating it for CHF.

RE: Pleural effusion cat case to discuss

Rob Loxley — Sun, 18 Dec 2016 21:18:15 GMT

[quote user="Beats"]Prognosis-wise, what do others give (say as a % that will have a decent quality of life with treatment for at least 9 months) for a geriatric cat with[/quote]

I think it's so variable to be useful to guess at. I generally find neoplastic effusions don't do well and heart failures can do well. With the heart failures the ones that respond well initially seem to do better longterm. I gues it's like the lymphoma cases that go into complete remission tend to do better than the ones that respond poorly to initial treatment. Concurrent diseases also influence - thyroid can be treated and renal generally makes heart failure treatment more cautious IME

RE: Pleural effusion cat case to discuss

serena holmes — Sun, 18 Dec 2016 19:57:04 GMT

My 2 worst ones were old cats-both presented with severe right and left disease, pleural effusion, abdo effusion and peripheral oedema, one lasted a year on high dose meds-frusemide and prilactone-kidneys got him in the end-likely precipitated by meds, the other lasted 6 months-decompensated on the highest dose meds-frusemide/prolactin/vetmedin

RE: Pleural effusion cat case to discuss

Beats — Sun, 18 Dec 2016 19:42:42 GMT

Thanks for all thoughts thus far!

[quote user="Emily Rainbow"]Did you do any post-centesis imaging?[/quote]

only the basic echo few days later.

Prognosis-wise, what do others give (say as a % that will have a decent quality of life with treatment for at least 9 months) for a geriatric cat with:

1) Severe dyspnoea on presentation

2) Severe dyspnoea on presentation known to be large-volume pleural effusion

3) Severe dyspnoea on presentation known to be large-volume pleural effusion due to right/left congestive heart failure

4) Severe dyspnoea on presentation known to be large-volume pleural effusion due to neoplastic process

RE: Pleural effusion cat case to discuss

Beats — Sun, 18 Dec 2016 19:42:38 GMT

Thanks for all thoughts thus far!

[quote user="Emily Rainbow"]Did you do any post-centesis imaging?[/quote]

only the basic echo few days later.

Prognosis-wise, what do others give (say as a % that will have a decent quality of life with treatment for at least 9 months) for a geriatric cat with:

1) Severe dyspnoea on presentation

2) Severe dyspnoea on presentation known to be large-volume pleural effusion

3) Severe dyspnoea on presentation known to be large-volume pleural effusion due to right/left congestive heart failure

4) Severe dyspnoea on presentation known to be large-volume pleural effusion due to neoplastic process

RE: Pleural effusion cat case to discuss

Emily Rainbow — Sun, 18 Dec 2016 08:44:04 GMT

Did you do any post-centesis imaging? To evaluate cardiac silhouette and for potential space occupying lesions?

RE: Pleural effusion cat case to discuss

Kate Richardson — Sat, 17 Dec 2016 23:31:41 GMT

Yes why Martin Atkinson ?

RE: Pleural effusion cat case to discuss

Anthony Todd — Sat, 17 Dec 2016 23:30:46 GMT

[quote user="Martin Atkinson"]This is cardiac disease whether there is a tumour of not.[/quote]

Why? [and I didn't give the star] you don't get funny cells in cardiac disease do you??

RE: Pleural effusion cat case to discuss

Virginia Campbell — Sat, 17 Dec 2016 22:41:20 GMT

[quote user="Martin Atkinson"]I would take the cytology with a large pinch of salt at this stage. [/quote]

Why?

[quote user="Martin Atkinson"]Add pimobendan and benazepril to the frusemide and it will probably work wonders.[/quote]

That is 5 pills the cat has to take per day. If it's eating remarkably well for a sick cat and isn't fussy about what's in the food, or if it's the kind of cat whose gob you can open and tuck pills into without fuss then grand. If it doesn't like being pilled and gets stressed....bad scenario. Of course we all know this...but it is often a limiting factor in my medication of creatures, especially those I think may not be long for this world.

RE: Pleural effusion cat case to discuss

Martin Atkinson — Sat, 17 Dec 2016 22:31:13 GMT

This is cardiac disease whether there is a tumour of not. I would take the cytology with a large pinch of salt at this stage. Add pimobendan and benazepril to the frusemide and it will probably work wonders.

RE: Pleural effusion cat case to discuss

Kate Richardson — Sat, 17 Dec 2016 15:17:29 GMT

Regarding Pro BNP measurement on pleural fluid, if it is negative, you can pretty much rule out cardiac disease. However if it is positive, it could be secondary to cardiac disease

RE: Pleural effusion cat case to discuss

Rob Loxley — Sat, 17 Dec 2016 13:41:24 GMT

I'd say your cytology and LA echo measurements trump the proBNP
Further imaging to look for a mass might be a consideration if surgery might be an option if operable - I had a cat with a small volume pleural effusion (which I appreciate yours isn't small volume) due to a lung carcinoma that did well after referral for a lobectomy.
But in your case I'd imagine it's a case of managing the effusion and monitoring quality of life for the cat.

RE: Pleural effusion cat case to discuss

Virginia Campbell — Fri, 16 Dec 2016 23:47:35 GMT

I would also use the phrase "days or weeks if you're very lucky, not months". I never like committing to the "How long has he got?" conversation with animals but I have had a few owners with animals as close at that to the Pearly Gates that were resisting the euth talk ask tearfully, "So she might not even last as long as a year then?" and the owners of an elderly barely-standing GSD with sheet-white gums and a palpably huge splenic mass ask, after "the conversation" whether it was still OK for the dog to go on holiday to the continent with them in a fortnight's time.

Some owners seem to grasp the seriousness but not the timescale involved, especially if it's not thin or anorexic.

RE: Pleural effusion cat case to discuss

Virginia Campbell — Fri, 16 Dec 2016 23:32:39 GMT

Poor kitty. IME the neoplastic ones refill really quite quickly and I'd push hard for euth in the very near future and let the other vets in the practice know that this case is out there, particularly if the owners are straw-clutchers.

What are the chances of this being a primary confined to a single, resectable lobe with no mets if it is happy to exfoliate its cells into the pleural cavity like this? I dunno but...probably v low. Maybe Gerry P will know.

If it doesn't refill badly enough to need euthed in the next few days I might send it for CT if the owners really want to do something but would explain that it's more than likely just getting "proof for euth".