Balancing options and expectations
A 16-year-old domestic shorthaired cat presented for evaluation of a large rostral mandibular mass (Figure 6). The owner had taken the cat to a different specialty hospital six months ago, and her account of the visit was that nothing could be done for the cat. Remarkably, the patient had become anorexic only 24 hours prior to presentation at our hospital. Closer evaluation of the oral mass revealed that it extended caudally just beyond the base of the tongue (Figure 7). The central portion of the mass was necrotic. Mandibular lymph nodes were remarkably normal.
When faced with challenging situations like this, strong consideration must be given to owner expectations. Long-term outlook was very unfavorable due to likelihood of metastasis in the future. Chances of achieving even adequate margins to minimize recurrence of this mass were not possible due to the caudal extent and bilateral involvement. A conservative approach was not an option in this case. The only two options for this patient were removal of the mass and most of the mandibular body bilaterally or euthanasia.
The owner was informed that the surgical option might not be well tolerated due the extent of the excision required and that euthanasia might be the best option since the patient’s quality of life could be severely compromised postoperatively. The owner accepted the risk of surgery in hopes of providing, at best, a few months of additional time with the cat; however, the owner indicated that no additional therapy (i.e., chemotherapy or radiation) would be considered, regardless of the histopathology results. Following approval for surgery, routine blood work and thoracic radiographs were performed, both of which were within normal limits.
Bilateral mandibular nerve blocks were administered. Radiographs revealed a large productive bony mass extending from the right to the left mandible with distinct areas of lysis (Figure 8). A bilateral mandibulectomy caudal to the missing mandibular first molars was performed. A portion of the rostral sublingual musculature was excised to allow caudal margins into normal tissue. The reconstruction involved closure with 4-0 monocryl suture in a simple interrupted pattern (Figures 9 and 10). Two-layer closure was utilized wherever possible. The patient was able to easily lap gruel from a saucer within 90 minutes of waking, exhibited no signs of discomfort and continued to eat well for 48 hours.
Two days postoperatively, examination revealed partial dehiscence of the right caudal incision due to contact with the right maxillary fourth premolar (tooth 208). The tooth was surgically removed, and the dehisced region was debrided and sutured. The patient continued to do very well for several months postoperatively. The only complication was a dark discoloration of the tongue due to exposure outside the oral cavity and grooming (Figure 11). Histopathology results revealed that the mass was lymphoma.
Five months after surgery the patient developed right mandibular lymph node enlargement. Biopsy confirmed lymphoma. Despite the owner’s original wishes, she opted to proceed with chemotherapy at an oncology specialty service since the cat had done so well following surgery. Unfortunately, chemotherapy was unrewarding and five weeks later the patient was euthanized due to progressive lethargy and anorexia.
Along with the surgical challenges, another challenge with cases like this is providing accurate information to owners to allow them to make a proper decision. Despite the progression and eventual demise of this patient, the owner was very thankful that she was able to spend several more months with her cat and provide him a normal quality of life during that time.
Dr. Brett Beckman lectures and sees patients at Affiliated Veterinary Specialists, Orlando, Fla.; Florida Veterinary Dentistry and Oral Surgery, Punta Gorda, Fla.; and Animal Emergency Center of Sandy Springs, Atlanta. Visit veterinarydentistry.net for more information.