Dear Lizzi:
Because I know that you want honesty, and there is the chance that many may
learn from this, here goes.
>Dr. Williams and FMLers who might learn from this,
>
>Dr. Williams, you responded to my inquirey re: the weaning of pred from
>Fang, due to his BG reading of 200. He had been on 1 ml.twice a day due
>to his terminal condition (liver tumor). You asked me what type of cancer
>it was, and if he was showing any signs of insulinoma at this time. His
>BG reading was down to 45 two months ago with his seemingly returning
>insulinoma. No other signs, even when he had it last winter.
The operative question here is what type of tumor is in and around the
liver. You offhandedly call it a liver tumor, but what you mean is a tumor
in and around the liver. Did it arise in the liver, or come from somewhere
else. Liver tumors, or tumors that are composed of liver, are very rare.
What we are dealing with is more likely a metastatic neoplasm, originating
in another organ - maybe a lymphoma, or something else.
The problem with the metastatic insulinoma is two-fold:
1) Insulinomas in ferrets, as opposed to the dog, rarely if ever
metastasize (or leave the pancreas.) I've never seen one out of hundreds
of insulinomas that I have done - while its been reported in several books,
a microscopic evidence has never been presented.
2) In cases of metastatic insulinoma, the increased tumor load produces
otrageous amounts of insulin - these animals go hypoglycemic fast, and
stay that way. Fang is responding appropriately to the pred - but there
is no way that if this was an insulinoma, he would have a BG of 200.
>When the vet opened him up this time, he said his pancreas didn't look
>that bad,but he didn't mess with anything too much (inspect carefully)...
>There were little speckles of insulinoma in several places in his body,
>and his spleen was slightly enlarged.
This is a common mistake - ferrets often have little nodules of tissue
around their body - speckles of fat in the liver, ectopic adrenal tissue,
little nodules of fat necrosis in the mesentery. During the surgery, soem
tissue should have been taken from somewhere - if not a small fragment from
the liver, then one of these nodules. Because most solid tumors are not
extremely vascularized, a fragment from anywhere would have given us the
knowledge of the tumors identity, and how to treat it at this point, or at
least whether the prednisone is helping or hurting. Spleens are enlarged
all the time in older ferrets - it is usually due to chronic GI
inflammation, and the chance of it being related to the neoplasm are very
remote.
>He said as soon as he saw the condition of the liver, he knew there wasn't
>much hope. He had removed a little piece of the liver last Feb. during
>his pancreatectomy and right adrenal cryosurgery, because it didn't look
>good to him then, either. The lab report came back at that time with:
>(whatever the term for nutmeg liver is), but not cancerous. They diagnosed
>it being due to lack of caloric absorption (something like that; I can't
>find the report) as a result of the insulinomic condition. (this is the
>best of my recollection).
That is called hepatic fatty change, and is the result of mobilization of
fat. It is commonly associated with metabolic conditions in which ferrets
don't eat well - it doesn't have to be starving. I see this in so many
ferrets that it is of little significance in most sick ferrets.
>The tumor he found now was quite large (and soft), and sort of intertwined
>in and around the liver. He thought it was from the insulinoma, but did
>not mess with it any more than he had to. (you had said that it is not
>common for liver tumors to be insulinomic related?)
Very much so.
>Knowing it was more important to me to have him live throught the surgery,
>he treated it delicately, and sewed him back up. I have to say here, that
>he is a great ferret vet...remember I told you he has attended Weiss's
>lectures and calls him when needed...other vets refer ferrets to him from
>other cities, he has a great track record,etc.
I'm not sayng that he isn't - but one more minute to harvest a small piece
of tumor from anywhere would have allowed me to be able to tell you with
certainty what to do at this point. What I am hopeful is that other owners
and especially vets in a similar situation will not simply sew up a ferret
with an "inoperable" tumor unbiopsied. In this case, if we ever want to
know what type of tumor Fang has, then we will need to do an autopsy - a
much more emotional procedure for most owners, and one that from the
doctor's point of view, has a much lower chance of ever being carried out.
>But as I said before, he is not God, and maybe you would have done a more
>thorough investigation of the tumor itself. I wish I knew what kind it
>was, but my vet basically said it was aggressive, and was gently honest
>with me that there wasn't anything that could be done surgically.
I don't disagree, and I hope that I am being as gentle as he - but I think
that you want the honesty, and obviously want other people to learn from
your experience.
>It is important to say that blood was sent to the local (huge) hospital
>due to the fact that they could run a complete test quickly ; his BG was
>120 at that time. I had him on 1/2 ml. of pred twice a day the week
>prior to surgery, and it had elevated it only to 50. Someone on this
>list suggested the diseased liver can cause fluctuation of the BG...is
>this true?
Yes, but if the liver had the same chancge as it did before, hepatocellular
fatty change does not result in significant BG value shifts - you need true
liver failure to do that.
>Then the weakness in the hind legs began when holding himself up to
>urinate; the only time we noticed weakiness in the hind legs at all. He
>has two big bags of fat in the groin area, that actually look like big
>testicals when you look at him from the rear. They sort of hang under
>his tail. This is why I thought he would be more comfortable if he lost
>some of that pred fat if possible.
At this point, I wouldn't expect him to be able to lose any weight. The
idea is to keep the weight on him - malignant neoplasms tend to cause
progressive weight loss, but it is not a good thing and wouldn't be used
for body sculpting of the type you are hoping for.
>Then when his BG came in at 200, I thought it would be okey to wean him
>off the pred. Now we are at 1/2 ml twice a day, and HE IS LETHARGIC
>AGAIN! He only gets up to eat, then goes back to bed. SHOULD I UP THE
>DOSAGE AGAIN? I'm afraid you might be right, that it is the only thing
>keeping the tumor in check. PLEASE RESPOND....
At this point, assuming that Fang does not have a significant amount of
time left, my best guess would be to up the dosage again. A BG of 200
does not concern me as much as does making his last days as comfortable
as possible. A 200 BG will not cause significant dysfunction in the short
term. Assuming that the prednisone is helping, I would up the dose.
What are we looking at as a tumor here? I wasn't there to see, so this is
just an educated guess - my first choice is a metastatic adrenal tumor -
rare, but they do happen - and when they do, they generally extend into
the liver. A lesser possibility is lymphoma - the fact that he is still
with us lessens the possibility.
With kindest regards,
Bruce Williams, DVM
[Posted in FML issue 3296]
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