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Nine Lives

By: Ashley Berke Date: Jun 3, 2015

Since birth, Brianna has fought against the odds. Born in an abandoned car on a farm in upstate New York, the dauntless calico was discovered by neighbors who bottle-fed her after learning that her mother had been hit by a car. Years later Brianna went missing for five days, only to be discovered behind a feed bin in a barn. Part of her tail had been stripped to the bone, evidence that she had survived an attack.

Despite Brianna’s proven resilience, owner Sally Steinmetz expected the worst for her nine-year-old cat when she learned that a large mass was occupying two-thirds of her chest cavity. “I immediately thought her days were numbered,” she said.

A Dismal Diagnosis

In February 2014, Steinmetz discovered swelling on Brianna’s cheek. Her local veterinarian in Churchville, MD, scheduled an appointment for a dental procedure. “I wasn’t very concerned,” Steinmetz said. But when the time came for Brianna to be anesthetized, her vets noticed that she was having difficulty breathing.

A subsequent X-ray revealed a very large mass in Brianna’s chest. The tumor was so big, in fact, that it occupied a large portion of the thoracic cavity, preventing Brianna’s lungs from expanding. Her primary care veterinarians thought there was a good chance that the swelling on her cheek was related.

The swelling can be seen on Brianna's right side of her face.

“At this time, I brought Brianna home, where I was determined to make her last days as pleasant as possible,” Steinmetz said. “The vets and I discussed euthanasia.”

Over the course of a week, the mass on Brianna’s face grew quickly. “I really thought she had reached the end of the road when her cheek swelled up to the size of a walnut and her eye was half closed,” Steinmetz added.

But then the mass suddenly drained and the swelling dramatically improved. Steinmetz decided to make an appointment at Penn Vet’s Ryan Hospital. “I figured I owed Brianna a trip to see an oncologist,” she said. 

Hope for Brianna

Steinmetz brought Brianna to Penn Vet’s Comprehensive Cancer Care service. She explained that the cat presumably had two different masses – one in her chest and one in her mouth.

Upon examination, experts in Penn Vet’s Dentistry & Oral Surgery service determined that Brianna was suffering from a dental abscess – not cancer – and would simply require a tooth extraction.

A CT image of Brianna's chest showing the thymoma.

After the extraction, Brianna’s oncologists turned their attention to her chest mass. Based on a combination of imaging studies, including a CT scan and ultrasound, the team deduced that Brianna most likely had a thymoma, a large tumor that affects the thymus gland. Experts in Penn Vet’s cytology department agreed, even though thymomas are rarely seen in cats.

Brianna in ICU after the first surgery“My hope was to make Brianna’s last days more comfortable, possibly with some chemotherapy,” Steinmetz said. “Never in my wildest dreams did I think there could be a surgical solution!”

Brianna’s surgery lasted three-and-a-half hours. The mass had adhered to the cranial vena cava (large vein in the chest) and the pericardium (membrane surrounding the heart). Due to the size of the mass, Brianna’s entire sternum had to be opened to remove it from her chest.

“I have nothing but praise for the Comprehensive Cancer Care service,” Steinmetz added. “When you bring in a pet with cancer, you worry about so many different things. But everyone worked together efficiently as a unified team and came through for Brianna.”

Following surgery, histopathology results confirmed that the mass was indeed a very large, but benign, thymoma.

After several days of recovery in the Intensive Care Unit, Brianna was able to return home. But her days at Penn Vet were far from over.

Respiratory Distress

After the second surgery, the fluid and seroma in Brianna's chest persisted.Less than a month later, Steinmetz found Brianna restless with slightly labored breathing in the middle of the night. After a call to Penn Vet’s Emergency Service, she decided to make the 90-minute trip from Havre de Grace, MD, to Philadelphia. Brianna’s condition worsened during the car ride, leading to respiratory distress.

“It was one of the most harrowing experiences of my life,” Steinmetz recounted. “Brianna was just about dead by the time we arrived.”

An emergency chest ultrasound showed fluid in Brianna’s chest surrounding her lungs, as well as a seroma, or pocket of fluid, around her incision site. 

A chest tap was performed, and a large amount of fluid was removed. After this occurred, Brianna’s incision site also improved.

According to Dr. Christin Reminga, Resident in Critical Care, the sternotomy site had failed to heal properly, and a portion of Brianna’s sternum had become unstable.

Because of this, fluid from the seroma was flowing into Brianna’s chest cavity. Unfortunately for the stoic calico, a second surgery was necessary.

Surgery #2

Sally visits with Brianna after the second surgery.Brianna’s surgeons performed a second chest surgery, which stabilized the sternum and reduced the seroma.

The fluid collected from Brianna’s chest was cultured, revealing a multi-drug resistant infection. As a result, surgeons placed beads infused with the antibiotic Amikacin into the incision site to treat the infection.

Use of these “antibiotic-impregnated beads” has been an effective method in human orthopedics to treat and prevent local infections.

“The beads allow us to infuse high concentrations of an antibiotic at a local site for a known period of time, with limited, if any, systemic side effects,” Reminga said.

Following surgery, Brianna’s sternum remained intact and her respiratory issues ceased. But she experienced significant swelling, and unfortunately, the seroma remained. 

The top x-ray shows that the antibiotic beads had moved from the incision site. The bottom x-ray shows the beads in their proper place. “Seromas can be very frustrating,” Reminga said. “They take a really long time to heal, and they are very difficult to close without constant drainage from the site.”

Their goal was to manage Brianna’s seroma without putting in drains, to avoid potential infections, Reminga said. Warm compresses were placed over Brianna’s abdomen to dilate the vessels and enhance resorption of the fluid. Over the next few weeks, Steinmetz made several trips to Penn Vet’s Ryan Hospital so that Brianna could be closely monitored. 

Brianna’s respiratory rate remained strong, but the seroma kept growing. X-rays showed that the beads had significantly moved around in her chest cavity. Although the seroma had been tapped as much as possible, there was simply too much space between the beads to allow for proper adherence to surrounding tissues.

Steinmetz was faced with two options. Surgeons could remove the beads and use a vacuum-assisted device on the wound to pull the tissue edges together while simultaneously removing excess fluid. Or, Brianna could be treated with medical management.

At home, Brianna wore snug body bandages to compress the seroma and prevent additional fluid from accumulating.

Steinmetz opted for medical management, which required substantial supportive care at home. Over the course of several months, Brianna wore snug body bandages to compress the seroma and prevent additional fluid from accumulating. Steinmetz was tasked with limiting Brianna’s movements, since increased activity could promote fluid accumulation in the seroma. Brianna was placed on strict cage rest until the seroma was resolved. 

By July 2014, Brianna was able to resume normal activity.

Fearless Feline 

Dr. Christin Reminga with Brianna at discharge.During Brianna’s most recent check up in April 2015, everything looked great. X-rays show that the beads are still in place, the seroma has disappeared, and the thymoma has not reemerged. Brianna will return to Penn Vet every four months for re-checks, but her prognosis is very good, according to her vets.

“Brianna is a survivor, despite having the odds stacked against her. She has many, many lives,” Steinmetz said. 

“People probably wonder if I would go through all of this again. For a cat like Brianna, I would,” she continued. “But not all cats could go through what she did. She’s just so tolerant, gentle, and loving.”

The combination of an “extremely dedicated” owner and a “sweet as can be” patient was important to success in this case, Reminga said.

Brianna at home in the sun room“Medicine is not always perfect. In Brianna’s case, there weren’t a lot of ways to avoid the complications, so we had to troubleshoot along the way,” Reminga added. “But this just goes to show how incredible patients and their owners can be, and how dedicated they are. Of course, all of us at Penn Vet are incredibly dedicated, too. But the way that Sally kept fighting for Brianna left a lasting impression on me.”

And it seems the admiration is mutual.

“Everyone I encountered at Ryan Hospital – from the parking attendants and receptionists to the students and doctors – was extremely caring, friendly, helpful, and knowledgeable,” Steinmetz said. “Brianna is a loving member of my family, and thanks to Penn Vet, she has been given another chance at life. It is truly a miracle and I am forever grateful.”