Pain Management Case of the Month: Mike—A 13-Year-Old Cat with Probable Metastatic Disease

Mike, a 13-year-old cat, had a decreased interest in eating and self-grooming. Mike’s caregivers noted moderate weight loss, oral malodor, and bloody discharge on his lips. Here’s what happened.

by Jan Bellows, DVM, DAVDC, DABVP (Canine and Feline)

Signalment and History

“Mike” is a 13-year-old, 4.5-kg neutered domestic shorthair cat. Historically, during the past month, he has had a decreased interest in eating and self-grooming. Mike’s caregivers noted moderate weight loss, oral malodor, and bloody discharge on his lips. Mike’s referring veterinarian reported marked oral inflammation as well as a large mass in the right caudal oral cavity. He suggested referral to a dental specialist.

Figure 1: Mike, before treatment

Figure 2: Examination showed marked inflammation and swelling of the right caudal oral cavity

Physical Examination and Diagnostics

Mike’s referring veterinarian was advised prior to the referral that preoperative testing including CBC, serum profile, urinalysis, chest/abdomen radiographs, ECG, and blood pressure testing were indicated. The radiographs revealed a markedly enlarged liver. All other tests (including liver enzymes) were essentially normal. Abdominal ultrasound confirmed hepatomegaly with multiple hyperechoic liver masses consistent with malignant neoplasia. In that Mike did not outwardly appear to be in pain and was still eating, his caregivers (even with the grave prognosis) desired to proceed with further assessment. General anesthesia to perform cone beam CT to evaluate the extent of the caudal oral mass was scheduled.

Conscious examination of Mike found him to be apparently bright and alert with a grimace score of 3/10 (action units of 1 attributed to ear carriage, eyes, and head and shoulder positions) (Figures 1, 3). Oral examination confirmed marked inflammation and swelling of the right caudal oral cavity (Figure 2). An intravenous catheter was placed. Cerenia (extralabel for cats @ 1 mg/kg) and methadone (0.2 mg/kg) IM were given for premedication. Alfaxalone (3 mg/kg) IV was administered for induction. Mike was intubated and maintained on 1.5% isoflurane. Maxillary and mandibular regional nerve blocks were accomplished injecting mepivacaine (0.1 mL/area). Cone beam CT (Xoran) was examined revealing marked right caudal mandible and maxilla destruction consistent with malignant neoplasia (Figures 4, 5). Fine needle aspiration of the left caudal oral mass was performed, revealing marked anisocytosis, anisokaryosis, increased nuclear/cytoplasm ratio, and multiple nucleoli consistent with malignancy.

Figure 3: The Feline Grimace Scale was developed by researchers at the Université de Montréal.

PC_grimace scale.PNG

At that point, Mike’s caregivers were informed that the oral mass could be debulked but not excised with at least 2-cm surgical margins and that the prognosis was grave. The decision was reached to place a pharyngostomy tube, debulk as much of the oral mass as possible, and extract those teeth associated with marked gingival inflammation. After surgery, Onsior injection (2 mg/kg) was administered SQ, as was meloxicam (0.2 mg/kg) SQ. Mike’s caregivers were instructed to administer buprenorphine oral solution 0.3 mL (0.3 mg/mL) twice daily and Onsior Feline 6 mg one tablet daily for six days.

Figure 4: CT scan showed marked right caudal mandible and maxilla destruction consistent with malignant neoplasia

Figure 5: 3-D reconstruction demonstrating left caudal mandible destruction

Soon after the procedure, Mike’s caregivers were asked to text an image of his face. Based on an increased grimace score of 8 (decreased size between the eyelid opening, lower head carriage, muzzle tense with whiskers positioned upward) consistent with moderate to severe discomfort, a new pain relief protocol was recommended (Figure 6):

  • Amantadine 3 mg/kg PO daily for 21 days
  • Buprenorphine 0.01–0.02 mg/kg buccally Q 12 H for 2–3 days
  • Meloxicam 0.05 mg/kg PO daily for 4 days
  • then 0.05 mg/2 kg PO daily for 4 days
  • then 0.05 mg/cat PO daily for 4 days
  • then 0.05 mg/cat every other day for 5 days

Within four days, the response was dramatic, with the grimace score at 2. Mike still has a terminal disease but for now appears to be comfortable and enjoys lying on the windowsill in the sunlight.

Figure 6: Based on the degree of pain shown in this picture, Mike was given a new pain-relief protocol

Figure 7: Mike, with a grimace score of 0, three weeks after surgery

Discussion and Conclusion

Often, caring clients are presented with difficult decisions on what to do when their dog or cat has a terminal disease. Many are not ready to let go, nor are their pets, who may be suffering in silence. A week after surgery, Mike’s caregiver texted, “He’s doing better. Much more alert. Moves room to room. Not eating or drinking yet on his own. Hasn’t lost weight.”

In this case, the clients, referring veterinarian, and I were on the same page. Now that there is an evidence-based grimace scale available for consideration, treating veterinarians can gauge patient discomfort and, if needed, prescribe pain relief and anti-inflammatory medications.

References

Epstein, Mark E., Ilona Rodanm, Gregg M. Griffenhagen, Jamie Kadrlik, Michael C. Petty, Sheilah Robertson, and Wendy Simpson. 2015. “2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats.” Journal of Feline Medicine and Surgery 17, no. 3 (March): 251–272.

Evangelista, Marina C., and Paulo V. Steagall. 2021. “Agreement and Reliability of the Feline Grimace Scale Among Cat Owners, Veterinarians, Veterinary Students and Nurses.” Scientific Reports 11, no. 1 (March): 5262.

Gowan, Richard A., Randolph M. Baral, Amy E. Lingard, Melissa J. Catt, Wibke Stansen, Laura Johnston, and Richard Malik. 2012. “A Retrospective Analysis of the Effects of Meloxicam on the Longevity of Aged Cats with and Without Overt Chronic Kidney Disease.” Journal of Feline Medicine and Surgery 14, no. 12 (December): 876–881.

Mathews, Karol, Peter W. Kronen, Duncan Lascelles, Andrea Nolan, Sheilah Robertson, Paulo Vm Steagall, Bonnie Wright, and Kazuto Yamashita. 2014. “Guidelines for Recognition, Assessment and Treatment of Pain.” Journal of Small Animal Practice 55, no. 6 (June): E10–E68. 

Sparkes, Andrew H., Reidun Heiene, B. Duncan X. Lascelles, Richard Malik, Libertat Real Sampietro, Sheilah Robertson, Margie Scherk, Polly Taylor, ISFM, and AAFP. 2010. “ISFM and AAFP Consensus Guidelines: Long-Term Use of NSAIDs in Cats.” Journal of Feline Medicine and Surgery 12, no. 7 (July): 521–538.

Discussion by Mike Petty, DVM, CCRT, CVPP, DAAPM

This case is really about pain and its implications on quality of life. Many owners would not have pursued this procedure for a variety of reasons: financial cost, emotional toll of caring for a terminal patient, time needed to care for a cancer patient, and poor prognosis. And had not the author done such an amazing job of assessing, treating, and reassessing the pain, Mike might have been euthanized within a few days of the procedure.

Too often, I get cases that come to me because the owner (often upset or angry) just wanted a few more weeks with their terminal pet, but their veterinarian kept encouraging euthanasia. I have had some of these patients go for several months once their pain was controlled. We all have the resources to treat cancer pain, and if we don’t, we can reach out to pain practitioners or specialists to help us.

Finally, my last comment is to use validated pain scales, and use them correctly, choosing them for acute/surgical or chronic pain evaluation. The scale that was used here is an excellent one developed at the University of Montreal.

Michael C. Petty, DVM, CCRT, CVPP, DAAPM, is in private practice in Canton, Michigan. He is a frequent national and international lecturer on topics related to pain management. Petty offers commentary on each Pain Case of the Month (and occasionally writes one himself). He was also a member of the task force for the 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats.
Jan Bellows
Jan Bellows, DVM, DAVDC, DABVP (Canine and Feline), has been practicing since graduating Auburn University School of Veterinary Medicine in 1975. He became board certified by the American Board of Veterinary Practitioners in 1986 and by the American Veterinary Dental College in 1990. Bellows is currently the president of the Foundation for Veterinary Dentistry, which oversees the Journal of Veterinary Dentistry, the Veterinary Dental Forum, and veterinary dental research and outreach. His practice, All Pets Dental, is located in Weston, Florida.

 

Photo credits: Photos courtesy of Jan Bellows

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