Liver cancer in a rabbit & palliative care.

Question
QUESTION: We have a brown female mini-lop rabbit by the name of Fluffles who is bonded with a male mini rex.  Both have been 'fixed'.  Unfortunately, we do not know the exact age of Fluffles nor her medical history as we rescued her from a cardboard box outside an appartment building.  Our veterinarian estimated she was around 3 years of age due to her molar spurs, which we had grinded down.  She would be about 5 years old then today.  Fluffles has been on the motility drug Metachlopromide for about a year now as prescribed by our veterinarian due to her large chronic 'doughy' mass.

Almost a month ago, we noticed her fecal droppings reduced in size.  A quick trip to the vet diagnosed her as still too much "dough".  An X-ray was taken and a small arthritic fracture was noted on her mid-back.  Our vet figured that perhaps the nerve cells were sending pain stimulii and reducing motility in her gastro-intestinal tract.  A steroid shot was administered, an anti-biotic for pasteurella (she is a carrier), and lots of fresh pineapple juice so that the enzymes can break down more "mass".  Her weight was 3.1 pounds (down from her healthy 4.0 pounds).


She is fed a diet of mostly 75-80% timothy hay, 15% fresh vegetables (no cauliflower or cabbage) and the occasional fruit treat 5%. We noticed she was not eating the hay as much so we opted to feed her alphafa pellets to regain weight (mistake).  We take care not to purchase mouldy hay for fear of mycotoxins.


We took her into the vet a week later as she would often flop down on the floor with her two legs out to the side on many occasions.  Two more X-rays were taken as the vet felt some sort of hard mass near the liver.  Sure enough, the X-rays revealed a growth along the liver "almost the size of an egg".

Blood tests revealed that her Alanine Aminotransferase levels were at 350, her blood sugar slightly up, her urea slightly up.  (Blood sugar likely from all the fresh pineapple we were giving her).

Our vet's differential diagnosis is that Fluffles has a liver tumor.  We can opt for a liver biopsy to determine if the tumor is malignant or not.  Here is the tricky part - even if we know what stage the liver tumor is in, we aren't in a position to treat it via surgery, as our vet recommends against any abdominal surgery for rabbits.  

Currently right now, we are researching on the internet for various options.  There seems to be a *LOT* of research on rabbit liver, mostly because rabbits are used in liver research - but nothing that really helps us at this stage.  Everything from electro-magentic stimulation to hypertonic saline injections.  We've read about the use of milk thistle extract and supplement of B vitamins from your site and will discuss at great detail the recommendations you have given to a previous user with our vet.

Currently Fluffles is on a High-Cal diet, no more alphafa, loose timothy hay, timothy pellets, vegetables and a 7 day prescribed antibiotic.  Her disposition is good - she still explores new areas with her mate, has an appetite for the pellets, and charges at the sweeping broom (her enemy).  However, she is still underweight.  Out vet figures that at this point, she has reached the palliative care stage, and the best we can do is make her comfortable and happy for the rest of her days.  We are debating going forth with the liver biopsy.  I was wondering if perhaps a second opinion would suggest the same.

My apologies for the length of this message.  Thank you very much for your time.

ANSWER: Dear Renay,

Did the vet recommend the pineapple juice?  And did he specify that it must be *raw*, not canned/cooked?  I ask because this is often a gauge of just how experienced and current in rabbit medicine a vet is.

First, cooked pineapple juice will not break up masses in the intestine:  the enzymes are denatured and inactive.  Second, even raw pineapple juice is far too high in sugar to be healthy in an already-compromised intestine.  Third, if your bunny's pancreas is working normally, pineapple juice should not give her high blood sugar.  (sheesh!)

You'll get far higher concentration of bromelain enzymes (with less sugar) by using a powdered (or crushed capsule) formulation of bromelain from a health food store.  Papain (papaya enzyme) is also used in some cases.  But note that these enzymes do NOT dissolve hair.  They are proteolytic (they break down protein), but not the protein comprisin hair (keratin).  The most they do is loosen mucus--but that can be done with adequate oral hydration, which is crucial for good intestinal health.  The enzymes won't hurt.  But without adequate hydration, they might not do much.

How is the vet planning to do the liver biopsy if not via abdominal surgery? Needle biopsy?  This is possible, but I know very few vets who do this.  If he is planning to biopsy via abdominal surgery, then I'd wonder why he would not remove the entire mass, if possible.  The liver is very good at healing itself if there is even a *little* bit of healthy liver tissue, and even if an entire lobe is removed, a patient can recover with good supportive care.

The question is:  will the biopsy change your treatment of Fluffies?  If not, then I would not put her through the stress of it.  Unless you want to risk having the mass removed entirely, then there is little point in a biopsy, if the vet is sure this is cancer (from the bloodwork).  A liver abscess also could be the culprit, but again--you certainly would not want to do a needle biopsy if that's the case, for fear of spreading the infection from an encapsulated abscess into the abdomen, where it could cause fatal peritonitis.

My recommendation at this point would be to find another rabbit-savvy vet for a second opinion:

www.rabbit.org/vets

Your present vet could be completely right about the situation, but it doesn't hurt to get one or two more rabbit-savvy veterinary heads involved, just to be sure you're doing all you can.

I hope this helps.

Dana

---------- FOLLOW-UP ----------

QUESTION: Thank you for your quick response!

First, about the pineapple: our vet did say it had to be from a fresh pineapple (not from a can).  He also explained, as you did, that it only broke the bonds which keep fur/hay together.  In his opinion, that helps flush out the mass because it breaks it into smaller quantities.  However, because of the blood test results, he advised us to stop the pineapple (and the metachlopromide), which we did.  My comment about the pineapple raising the blood sugar level was only an assumption I made.  Good to know I was wrong!  However, we are still giving her one Oxbow Papaya Tablet every second day.

In terms of the biopsy: the vet gave us two options, both by needle.  One option is for him to bring in a colleague who can do a needle biopsy via ultrasound.  The other is for him to do a blind biopsy.  He explained that there is a risk of breaking a blood vessel, but he feels somewhat confident in doing it blind as the tumour is big enough for him to grab on to (it's the size of an egg), and he says he can move it next to the abdominal wall.

He offered surgery as an option to remove the tumour, but is not confident that this is the best option.  He says he is concerned she may die from shock.  My bun has already lost approx. 25% of her weight this past month, so I am very concerned about this as well.

I am now hoping you can tell me about the following:
1) What kind of quality of life is Fluffles looking at?  I am almost completely decided against surgery, both because of the risk of shock and the difficult recovery she will have after.  However, does this kind of surgery have a good success rate?  Is there a good chance her quality of life will significantly improve from it?

2) You mentioned milk thistle in a different question you once answered.  I would like to give her some to help her liver.  How much would you recommend for a 3-3.5 lb rabbit?  Label indicates 1 teaspoon for regular human adult -  packaged in distilled water (no glycerin nor ethanol)

3) Is there anything else we should we looking at or considering?

Thank you again for your help.  It is very much appreciated.

Answer
Dear Renay,

(Sorry for the delay.  We had a couple of major bunny illnesses (hare with pneumonia; big bunny who was pushed off a small cliff by a hare and got all ow-y, etc.  We don't live like other people.) this week, and I got 'way behind!)

Well, I can't see Fluffles to make any kind of judgment about her ability to withstand a needle biopsy, but if the vet thinks this would be too hard on her, he's probably right.  I'll try to take your other questions one at a time:

1) What kind of quality of life is Fluffles looking at?  

Only Fluffles knows that.  But now you'll have to look for the subtle clues.  Inappetence, lethargy, unwillingness to move around.  But in the meantime, palliative care should include *good* painkillers.

2) However, does this kind of surgery have a good success rate?

This surgery is so uncommon in rabbits that I don't think there are enough for us to calculate a meaningful rate of success.

3) Is there a good chance her quality of life will significantly improve from it?

That's not really possible to know.  It's risky surgery, to be sure.   But if the tumor/abscess were gone and she did survive and recover, then of course her quality of life would be improved. But that could be a big "if."

4)  You mentioned milk thistle in a different question you once answered.  I would like to give her some to help her liver.  How much would you recommend for a 3-3.5 lb rabbit?

Since this is an herbal medicine, no hard data exist for dosages in humans, let alone rabbits.  It would probably be safe to give her one cc or so.  I'm just guessing.

5)  Is there anything else we should we looking at or considering?

Only that if this in an abscess, and not a tumor, that antibiotics could solve the problem.  You might ask about putting her on something, just in case.  If nothing else, it might help prevent secondary infections, since cancer will weaken her in general, and possibly cause immunocompromise.

I hope this helps.

Dana