ULCERATED (OPEN) TUMOR CARE
The following email thread is between me (Robin) and a top notch equine veterinarian who was
helping me with how to properly flush Havoc's ulcerated tumor, with notes to and from some
other members. It's posted here with her permission.
===================================
Definitely don't want to use pressure. I do all flushes with high volume but only gravity flow. Use
an old IV fluid bottle and an IV administration set. Just rinse out with hot water and Dawn dish
detergent periodically (Dawn doesn't react with plastics), rinse plain water then full strength
peroxide then distilled water.
You have to let his body wall off and separate any necrotic tissue at its own pace. When the
process is finished, it will flush right out of there. In the meantime, GENTLY bathing the tissues
in the cavity with the dilute water/peroxide solution will kill any free floating or surface tumor cells
and help prevent secondary bacterial infections. If he objects, you're using too much pressure.
These flushes aren't painful otherwise if you have the peroxide dilute enough. Good infection
control with dilutions as low as 1:20 peroxide:water (5% peroxide).
P.S. Tumor tissue looks pretty abnormal, that might be what you're getting a peek at.
--- In Feline_VAS_Support@yahoogroups.com, Robin wrote:
Jim, that's typical -- that's just the space that all that fluid was in. Think about it, that fluid was in
there in a pocket, you're now seeing the hole/pocket just like I'd told you you likely would. You
need to NOT poke around in there, not put anything in it, and flush it gently with sterile saline or
a distilled water:peroxide (about 10:1 water to peroxide or even as low as 1:20 particularly if it
starts to seem like its hurting or irritating him at all, or shows any signs of trying to bleed).
As noted before, Flush at least once a day, preferably twice a day, at least 100 ml fluid each
time. It may fill in with tumor or scar tissue over time -- but if it does, again, DON"T poke or try to
get stuff out of there unless it flushed out totally by itself. That's NOT normal tissue even if it
looks normal, and often times its very prone to start bleeding. Sometimes if it starts bleeding it
can be very difficult to get it to stop because its not healthy tissue and the blood supply to it isn't
properly formed either. That's also the area that is very likely to get infected, which is why you
need to gently flush it, at least 100 ml fluid each flush, and NO force or spray to the flush, just a
very gentle stream, almost dripping in. That's because if you use force you can cause things to
break lose that arn't ready to break loose, you'll likely irritate the bed there even tho you can't tell
it at first, and it will make things worse, not better in the long run. Any dead or necrotic tissue will
come off easily by itself and float out with the draining solution just by being gently flushed. You
DON"T want to force it off or irritate the lining inside that hole.
Robin
Subj: Fwd: Tumor Draining -- Jim, very important
Date: 7/25/04 3:15:29 PM Pacific Daylight Time
From: Mary M
To: Robin
--- In Feline_VAS_Support@yahoogroups.com, Robin wrote:
Jim, I hate to tell you, but that thing is going to continue to form just as much sera and continue
to drain, almost for sure. If it heals over, it will do so very temporarily -- and now that it has been
open, you really ought to put him on a low dose of clindamycin antibiotic (its cheap, and you can
probably use half the normal dose). Keep in mind that this is not a wound like you would
normally think of -- its a tumor, and it won't heal like a wound, it will just slowly get worse unless
you have it surgically removed (best option) or try using radiation or chemo. Even just putting
the cat on either piroxicam (not sure of cost) or second option prednisone (VERY cheap) will
help slow it and may help significantly reduce the drainage -- in some cats it can apparently
almost stop the sera formation and drainage, in others not.
I sure wouldn't use vodka on it -- just get some peroxide, which is even cheaper than vodka, and
some distilled water, and use a large 60cc syringe without a needle to mix about a 1:10 solution
of water to peroxide and gently drip the solution into the opening to flush it -- you need to flush it
preferably twice a day, but at LEAST once a day with at least 100 ccs of fluid, the more the
better.
Too much peroxide or anything that hurts when you use it may irritate the tumor bed in there the
longer you use it and start it bleeding and/or create MORE sera production and make things
worse and you don't want that. Don't squirt the solution in there with force, you want it to be a
very light stream or almost dripping in -- you don't need any force (which can irritate the tumor
bed also), you just want to put a large amount of fluid into it slowly to rinse out any debris and to
minimize the chances of infection. Once these things open, they're virtually immediately infected
and you've GOT to keep it from taking hold and making things worse.
Just get him laying comfortably where you can place a hand towel around the tumor to catch all
the fluid run-off, and its very easy to do and if you're doing it right, it shouldn't be uncomfortable
for him at all.
Robin
I saw a bunch of emails awhile back about what to do when a tumor opens. I didn't save them
because Scooby didn't have that problem, but last Friday his tumor opened just as I was looking
at him. It didn't burst like one I read about, fortunately. After consulting with his vet, I just dabbed
it with some tissue to absorb the liquid, then hit it with a little vodka. It did sting a little because
he let out one loud meow, but he didn't run away and let me pet him. He also didn't try to lick it
right away, which surprised me. The vodka was not only effective but safe, easy and cheap. A
little bit on the tongue wouldn't have hurt him. The tumor looks much better since it drained and
his fur (extremely shaggy) is starting to cover it again.
Jim and Scooby,
Boulder, CO
Subj: Fwd: Joe, re draining
Date: 7/25/04 3:44:40 PM Pacific Daylight Time
From: Mary M
To: Robin
--- In Feline_VAS_Support@yahoogroups.com, Robin wrote:
Hi Joe,
Did you shave about a 1 inch square or diameter circle where you were going to insert the
needle? Be sure you wash or at least use a bit of alcohol on the spot you're going to put the
needle in. If you use alcohol, let it dry for a minute before you insert the needle, you don't want
the alcohol to sting.
Does anyone know if weak betadine is safe for use on cat skin? I don't recall if I've ever seen it
on cat skin after surgery or for any preps??? Joe, ring your vet and ask if betadine is ok on cats,
don't use it otherwise... but if it IS ok, then put a little betadine (any grocery or pharmacy store,
get the plain betadine, NOT betadine scrub), then mix just a few drops with a small amount of
DISTILLED water, so the mix looks like weak tea, then use a bit of sterile gause and gently
rub/scrub the area that you've shaved and that will help reduce any infection risk. Let it dry for a
minute (not long) then you can insert your needle. AGAIN, CHECK WITH YOUR VET BEFORE
YOU USE BETADINE ON THE CAT!!! I don't know if iodine absorption thru the skin could be a
problem with cats or not (seems like they're awfully susceptible to that sort of thing with virtually
anything, so check).
Here's what I'd do to avoid the problems you ran into. IF you think you can remove the syringe
from the needle while leaving the needle inserted, then you can draw into the syringe and
remove it... LEAVE THE NEEDLE IN, don't withdraw it, and just hold a small container under the
end of the needle that would normally be connected to the syringe and let it keep draining. It
may take quite some time for it to drain most of the fluid, you can speed it up like I describe
below more on that in a minute.
I found that a 1/2 cup or smaller measuring cup worked fairly well to hold under the needle end
because typically for however he was laying, anything with higher sides was awkward for me to
hold and get under the end of the needle and not also press into him which I didn't want
because you want them to just lay there and ignore you . Then, hold the cup with one hand, and
gently use your other hand to sort of surround the outside of the swelling and keep the fluid from
moving away from the needle, gently press your other fingers down and slowly press/close in
toward the needle.
Try to avoid pressing right where the needle tip is and a smidge in front of that tip (envision in
your mind where it must be based on angle and how far you've got it inserted). You don't want
to poke it into flesh or tumor underneath, or back into the skin with that tip. Do this to basically
work all the fluid up to the needle and keep a little pressure on it, think of making that fluid
pocket smaller and smaller right around the needle tip using your hand and the cats body as a
"dam" to keep it from moving away from the needle tip. That way it'll continue draining out the
connection end of the needle until most is out of the cat. Let that outside end of the needle hang
down slightly lower than the needle tip, so it can easily drain with gravity.
Then, put the cup down, and pick up whatever towel or paper towel that you have right there
already ready for this, put it on his skin up under the bottom of the needle just a smidge below
where it goes into the skin and so the towel covers his fur. I used to actually roll or fold a couple
of paper towels somewhat loosely so I had maybe an inch diameter/wide long strip that I'd then
fold up on itself so the drainage would be sopped into the paper towel well and not onto his fur.
Do whatever you find works for you tho.
Then when you gently pull the needle out any drainage will go right into the towel. At that point,
hold the towel with one hand, and with the other again gently but firmly work the fluid towards
the hole in the skin from all sides at the same time if you can (I know, its a little awkward, but
pretty easy once you've done it a time or two.) That way it keeps draining until its pretty much
empty and there isn't much at all in there to keep draining. You may still get a few drips out in
the next few minutes even after you've quit pressing it all toward the hole, but likely it won't be
much if any.
The only way that I know of that it would have kept draining and gotten into the fur for a long
time as you had happen is if there was still a LOT in there and a lot of pressure from the fluid up
against the needle hole.
Then, clean the area again, pat it dry or let it dry, and immediately put a little dab of triple
antibiotic ointment on it. Just a little smidge right on the hole itself. That way he's not likely to be
bothered by it and lick it, and even if he does its a tiny smidge that won't hurt anything. So NOT
a pea sized dab, just a very thin layer, maybe pencil eraser size or smaller immediately on the
hole itself.
Another option for syringes -- call any other vet clinics within reasonable driving distance, try
EQUINE clinics in particular, explain the situation and ask if you can buy a half dozen 35 cc
(easier to handle, but not much better size wize) or better yet, 60 cc syringes (a little awkward
they're so big, you may want to support the needle hub with one hand and draw with the other
so the needle isn't moved/jiggled/poked too deep as you try to draw, since you only want the
needle just thru the skin, maybe 1/2 inch of the needle in him max). Anyhow, tell them you'd
really like the hub type, not luer lock, and get 19 gauge needles also. That way if you fill the
syringe up totally and remove the syringe, you can still drain out the needle end even without
reattaching the syringe. You can also try any farm/tractor/horse supply type stores anywhere
near you. Often they'll sell the larger syringes also. Or you can mail order them from places like
Omaha Vaccine, KV Veterinarian Supply, Valley Vet Supply, you can find those sorts of places
with a google search. (veterinary supply, that sort of search phrase)
Robin
Subj: Fwd: Re: Joe, re draining
Date: 7/25/04 3:46:49 PM Pacific Daylight Time
From: Mary M
To: Robin
--- In Feline_VAS_Support@yahoogroups.com, "joe"
joe... wrote:
Robin,
Thanks for all the detail, I appreciate all your help.
Joe
Subj: Fwd: Jim & Scooby & question for Kaye too
Date: 7/25/04 3:48:17 PM Pacific Daylight Time
From: Mary M
--- In Feline_VAS_Support@yahoogroups.com, Robin wrote:
Hi Jim,
Basically as long as the tumor is open/ulcerated it can get reinfected within days of being off the
antibiotic. Can you see what the drainage looks like? If its anything but perfectly clear with a
very slight yellow or reddish/brown tinge then its probably infected again.... in other words, if its
at all, even a slight bit opaque, or looks even a slight bit bubbly or foamy then its infected again.
Sometimes necrotic tissue can smell nasty, but with an ulcerated tumor I'd bet on infection WAY
before smell of necrotic tissue. If the antibiotics don't bother him, you can do it two ways -- well,
three I suppose.
You can put him on a full dose say one week out of every month -- BUT, if you notice ANY
change during the time he's off, like the sera drainage looks a litte cloudy (way before it looks
outright pussy, just cloudy means infection), then you'd put him back on it. Or, you can do a low
dose all the time, like half the normal dose -- that's what I did with Havoc. Or you can do a full
dose all the time. Anyway you cut it you want to watch for any change in the smell, any starting
cloudiness in the drainage, or any slightly bubbly or foamy look to it -- those all indicate infection
is starting and you want to hop on it pronto. If you've got it covered so there's a gauze or maxi
pad or something absorbing the drainage, the next time you change it, put your nose right up to
the pad and smell the pad -- if the pad stinks, its infection and NOT necrotic tissue smell. If the
pad has a good bit of drainage accumulated and NO smell, then necrotic tissue is possible...
Kaye -- if its necrotic tissue that's stinking, wouldn't it still smell pretty much as strong right after
flushing as before? Versus if the smell is much diminished after flushing then its infection? I
mean, is that another way to help differentiate between infection stink vs. necrosis stink?
Anyhow, if any of those signs occur when you're on a half dose of antibiotic you could try full
dose, or you may need a different antibiotic that covers a different spectrum of bacteria.
My understanding is that clindamycin is the best to use first, before amoxi or cefa or anything
that way because it gets more of the bacteria that are typically in an abcess type situation which
is approximately what an ulcerated tumor is.
I will note that you may want to stick with saline mixed with a little peroxide. About a 10:1 or
even 20:1 ratio because too much peroxide can irritate the tumor. The only reason I mention
that is because betadine, even really dilute, when it goes into something that's damp and stays
damp it can stink to high heaven itself!! To me its a very rotten smell too. I've had some people
tell me that they don't smell it that way, but oh, man, *I* do, it's like "whew, knock me over!!!"
Jim, when you had him on antibiotics before -- did the ulcerated area still stink? Did you notice
any significant change in the smell from before antibiotics to during antibiotics to after finished
with antibiotics? If so, that's again telling you that its infected.
Of course, if you like the way to really be sure also would be a CBC (bloodtest) to see if his
white blood cell count is elevated. If you put him on antibiotics and after say 4 days the smell
hasn't changed much, that may be warrented anyhow because you may need a different
antibiotic -- or you could just try a different antibiotic & see if it worked (with the vet of course
proscribing them so you know that you're getting a different bacterial spectrum coverage).
Robin
Subj: Fwd: New Member Introduction and Questions
Date: 7/25/04 4:09:39 PM Pacific Daylight Time
From: Mary M
To: Robin
--- In Feline_VAS_Support@yahoogroups.com, Robin wrote: Hi Barbara,
My Havoc has had three surgeries now for his VAS. Each time I got roughly 9 months to a year
before the next surgery. If it had been done correctly the first time there may not have been the
others, but so it goes, live and learn. His third was three weeks ago, and he'll be 18 this
summer. EVERY time his wound up with a big pocket of sera just as you describe. This last
time, it was too far spread before I finally got rid of the bad vet I had and got to an oncologist.
Anyhow, I'd started draining Havoc's every other day last August, and a month or two later it
opened on its own.
Your vet is totally correct that it won't heal. It may seal over again for a few days or even a week
or two, but the sera will just collect in there again, probably very quickly (Havoc's used to do 1/3
to 1/2 a CUP within 48 hours of being totally drained). In some respects its better to have it open
and draining, just because then it won't pop inside them and spread sera under the skin that
may have some cancer cells in it, it won't build up the pressure and weight on the cat, and won't
irritate the body as much as that pressure and build up would on top of the irriation from the
tumor that is already causing the sera to collect there.
The bad news is that as far as several regular vets (including the one crappy one), and a couple
of oncologists, as soon as the tumor is open, you might as well figure its infected. It really is best
to get them on antibiotics as soon as its open. You may be able to get away with a low dose
however -- maybe half the typical dose. From everything I've understood, clindamycin is by far
the best antibiotic to use and is a lot less likely to cause any GI upset than cefadrops or
amoxidrops too (commonly proscribed).
There is NO problem covering it, as long as you change the bandage at least once a day. The
opening should also be flushed at least once a day, ideally twice. That is not my personal
opinion, but was the opinion of several vets and two oncologists, Dr. Macy (VAS Task Force,
Colorado State Univ & many papers published) & his colleague Dr. Biller also Colorado State
Univ.
They also say that the cat, as soon as diagnosed with VAS, should be put on either piroxicam or
prednisone. For some cats that can drastically reduce the amount of drainage. For piroxicam,
the preferred of the two, the cat must otherwise be healthy, no existing renal problems, no
problems with being too thin or throwing up or anything that way. You do need to periodically
check their renal values on it to be sure its not causing any problems that way. If peroxicam isn't
possible, then prednisone should be used (or prednisolone, especially if there is any liver issues
since the liver converts prednisone into the active form (prednisolone). Havoc already had
chronic renal failure, so he couldn't use peroxicam, but they put him on 5 mg/day prednisone,
then after awhile the dose was slowly minimized so now he gets 2.5 mg every other day.
Inflammation from the cancer actually drives the cancer and speeds its growth, plus it produces
some things called cytokines that can also make the cat feel a bit under the weather -- so
putting them on an anti-inflammatory may really help both slow the cancer's growth and also
help keep the cat feeling as well as possible for as long as possible. Peroxicam is a cox-2
inhibitor (basically just like celebrex, etc. for humans) -- SOME fibrosarcoma really expresses
cox-2, so that's why peroxicam is the preferred of the two if the cat is otherwise heathy, because
if your cat happens to be the type fibrosarcoma that over-expresses cox-2 the peroxicam can
actually help kill the tumor a little bit. I wouldn't expect to see any visual improvement or
shrinkage from it, but as noted, it may really reduce the amount of drainage and help slow the
cancer significantly.
You don't want to use pure peroxide to flush it. The reason is that straight peroxide or even
stronger dilutions of it can be a too harsh on the tumor bed (which is what is inside that pocket
where the sera was, and is why it won't heal, because its not a wound, its tumor), and can
irritate it and sometimes even cause it to bleed -- none of which is good. You can use roughly a
1:10 dilution of peroxide to distilled water. If you note ANY irritation, either the cat complains, or
you see any bleeding that seems to start/increase as you flush, then you may need to go to
saline and/or drop the peroxide entirely -- or you may be using too much force -- you should use
at least 100 ml fluid to flush each time, and it should be a very fast drip or barely above that so
its a slow stream -- don't squirt it in.
I think Mick put some of my previous posts on how to properly flush into the files, but regardless
I'm pretty sure there is some information there... go thru those and then I can help more if
needed. Unfortunately I got flushing and covering tumors so the cat is pretty happy and can still
groom themselves almost everywhere but not get at the tumor about down pat. :-( I got so used
to doing it for so long that it seems downright odd to NOT have to do it everyday now since his
surgery!! :0)
Robin