Aleah - 10 y/o English Shepherd Mix, Tumors On Both Adrenals - Aleah has Passed

[Dave Ruske]

Hi, all. I'm here for our English Shepherd mix, Aleah. Together with her primary vet and an internal medicine specialist, we've arrived at a point where it seems we're dealing with an unusual case of Cushing's, and I'm looking for whatever insights someone out there might have.

First, the condensed history of our mutt. We adopted Aleah from a shelter in April of 2005 at an estimated age of 5 years old. She had been a stray, so there's no knowledge of her real age or medical history. The shelter spayed her at the time of adoption.

For years we had a healthy, happy dog with a fondness for fluffy squeak toys and Kongs stuffed with peanut butter. Last summer, once in a great while I noticed she'd sprinkle a few drops of urine during a walk. A urine sample showed some minor bacteria, so we put her on a course of antibiotics for a bladder infection and assumed that was that. It happened so rarely that it wasn't easy to know for certain.

By November I noticed more dribbling, more often. This time the urine culture was clear, though the urine was slightly dilute. Her vet suspected incontinence brought on by low estrogen, but before starting her on medication decided to x-ray for bladder stones. He didn't find any bladder stones, but noticed the liver was enlarged well past the ribcage, which kicked off a rapid series of tests and findings:


November 17, 2010: X-ray shows an enlarged liver. Abdominal ultrasound recommended.

November 22, 2010: Ultrasound shows coarse, enlarged liver with "an ill defined hyperechoic nodule on the left side (1.3 cm)." In addition, "Both adrenal glands are mass like measuring 1.5 cm on the left and 2.6 cm on the right." The radiologist informally described Aleah's adrenals as "ginormous" to her primary vet. She recommended testing for hyperadrenocorticism.

November 30, 2010: Aleah has an LDDS test. Baseline cortisol 2.8 µg/dL, 4 hour 3.7 µg/dL, 8 hour 3.2 µg/dL; no suppression indicates HAC, but can't distinguish between PDH or ADH. Also, a liver panel showed alkaline phosphatase at 902. This was 500 in routine blood work in March 2010, but wasn't considered alarming on its own.

December 10, 2010: Aleah has an HDDS test. Baseline cortisol 3.8 µg/dL, 4 hour 3.5 µg/dL, 8 hour 3.3 µg/dL. As a differentiating test, the expectation is that with PDH we'd see suppression, and PDH would be suspected because ultrasound had already shown both adrenals enlarged. But 15 to 50% of dogs with PDH fail to suppress, so this test was inconclusive. (In my opinion, the HDDS test, with its huge margin of error, is a waste of time. Knowing what I know now, I'd have went straight for endogenous ACTH testing, which turns out to be about the same cost as HDDS and quite reliable. I suspect information to the contrary is simply outdated.)

December 22, 2010: Aleah has an endogenous ACTH test. (NOT to be confused with the ACTH stim test used to check the effectiveness of therapy. Endogenous ACTH testing measures the dog's resting ACTH level, but as the sample must be carefully preserved, not all vet offices are able to offer this.) It took almost 2 weeks to get the result, but her ACTH level came back 0.0; utterly undetectable. Her pituitary gland is NOT involved in her Cushing's.

The internal medicine specialist was very surprised by this finding; the oncologist at the referral center had never seen both adrenals with tumors without pituitary involvement. Had we relied on the ultrasound alone, both adrenals being enlarged would have led us to incorrectly conclude PDH. But we went through some extra testing, because the adrenals were so much larger than normal, and it's ADH. Now the IMS is checking with peers to get some ideas about where we go from here, as am I.

A key question is whether we should be thinking in terms of surgery or treating with mitotane. Surgery would be an easy choice if Aleah was typical and there was one obvious adrenal to remove, but removing both would mean life-long treatment for Addison's. Maybe that's where we'll end up, but we're hoping that there'll be a better option.

If surgery makes sense, a second question is whether there's a non-invasive way of determining whether one or both adrenals are responsible for the excess cortisol, such as an MRI. The IMS says that a biopsy could tell us that as well as whether a tumor was malignant, but none of us wants to put Aleah through two surgeries if it can be avoided.

It concerns me reading that adrenal tumors run about 50% malignant. Does that mean that with two adrenals with tumors the odds that both are benign is 25%? Is it likely that a malignant tumor on one adrenal has metastasized to the other, and, if so, what are the chances that removing both adrenals would even give her a good chance for survival?

The crazy thing is that from outward appearance Aleah's still doing pretty well. Clinically, all we're dealing with is a little incontinence once in a while, a really good appetite, and a lot of sleeping. So how do I choose a path that doesn't make her remaining time worse?

I appreciate any insights or suggestions you might have.

Thanks,
Dave
Aleah's photos: http://gallery.me.com/ruske#100016

[AlisonandMia]

Hi and welcome,

Haven't got a lot of time to post but thought you might find this article interesting: http://www.k9cushings.com/forum/showthread.php?t=220

Alison

[Buffaloe]

Dave,

You sure have done a great job with Aleah's testing.

My dog had a large adrenal tumor on her left adrenal gland and had her adrenalectomy several years ago. It was a great thing for her. Our surgeon was really top notch; owns two wonderful facilities here in Phoenix and has a few board certified surgeons and Internist working for him. One time, a couple of years after Shiloh's adrenalectomy, I asked him about bilateral adrenalectomies for another person on this message board. He said, "I don't care if there is one tumor or two. All I care about is the size of the tumor(s) and their involvement with area blood vessels. If both adrenals are removed, the owner has to supplement the dog daily with a couple of things and some people don't want to get into all that."

Aleah is only ten, Shiloh was twelve at the time of her adrenalectomy. I think a consultation with a top board certified surgeon would be a great way for you to proceed. Your professionals should know a highly skilled and experienced bcs in your area.

If you treat Aleah medically, Internists are using Trilostane as well as Lysodren (Mitotane) to treat adrenal tumors. According to my surgeon, most of the younger ones prefer Trilostane and many of the older ones like Lysodren. Many dogs are not good surgical candidates (old, sickly, nearly inoperable tumors, etc.) so medical treatment is the only option. At my surgeon's facilities, they perform a good number of adrenalectomies and also treat lots of dogs with adrenal tumors with Trilostane and Lysodren. They have an 85% long term success rate with adrenalectomies. I don't think bilateral adrenalectomies are rare.

All the best to you and Aleah. BTW, I have an uncle and a bunch of cousins in Appleton.

Ken

[Dave Ruske]

That's a great paper, Alison, thank you! It's somewhat of a relief to read about a case as complicated as Chloe's with such a good outcome. The radiologist thought our dog's adrenals were large; Chloe's were several times bigger still, and she's a Papillon! Wow.

One question seems to be answered by this paper, unless something more has been learned since 2002: there doesn't seem to be any non-surgical way of determining whether adrenal tumors are functional vs. non-functional or malignant vs. benign.

The mortality rate of surgery on adrenal tumors is uncomfortably high ("In one study thirty-three percent of specialists reported a mortality rate of greater than 25%"). That alone might make me consider trying mitotane first, to see how well Aleah would tolerate it and whether it would be effective in controlling the Cushing's.

Surgical risks aside, I wonder what would be easier on Aleah: lifelong treatment for Cushing's or for Addison's? Unless by some miracle one of the tumors is non-functional and benign, and we figure out a way of knowing that, we're going to be managing one condition or another.

[zoesmom]

Sorry for the circumstance with Aleah that brought you here. We've got lots of members who have experienced adrenal tumors. Not sure if we've ever had a dog that had one on both adrenals, but I have heard of it. We also have those who chose surgery and those who've gone the medicine route for various reasons.

Just wanted to add one comment and will leave the adrenal commentary to those who have experience with it. I think that treating addison's is supposed to be a bit easier than treating cushings. And maybe cheaper?? (Not sure about that one. ) But in some European countries, they actually use lysodren/mitotane to induce permanent addison's because they feel it's easier to monitor and treat. And we have the occasional member here whose dogs go permanently addisonian - by accident - on the lysodren. Maybe one will see your thread and comment on the difference in treating one or the other. Also, I think there is a board for addison's, similar to this one. Maybe it would help to check out what they have to say, as well. Sue

[Dave Ruske]

Thanks, Ken. Consulting with a board certified surgeon sounds likely --- we'll need to weigh both options that'll likely be before us. We're blessed that our vet noticed the liver while looking for bladder stones, which led us to this early diagnosis; Aleah has stamina that many dogs requiring this surgery probably lack. That should improve the odds of a good outcome.

Our IMS thought that if we treated with medication, mitotane would be preferred to trilostane "because it will actually destroy the glands themselves and make follow-up interpretation for cancer concern easier compared to trilostane which does not stop the continued growth of the glands regardless of treatment. Trilostane only blocks the effects of the hormone, whereas the mitotane shuts down the gland completely."

I'll be speaking to the IMS again Monday or Tuesday. Hopefully we'll both have learned a little more about bilateral adrenal tumors by then.

Hope your cousins are bundled up... it's a chilly night up here!

[Dave Ruske]

Researching Addison's is a good thought, Sue. Two months ago I'd never heard of Cushing's, so it's been a crash course in learning that side of things... but I haven't read much on Addison's, yet. If we're going to even consider surgery, I should educate myself on it.

Thanks for the suggestion!

[Squirt's Mom]

Hi Dave,

A belated welcome to you and Aleah! :)

I have a few links on Addison's to help you in familiarizing yourself with that condition should it be in Aleah's future. You may have already found these in your research, but just in case..... ;)

Addison’s*

http://canineaddisonsinfo.com/
http://k9addisons.com/faqs/
http://pet-diseases.suite101.com/article.cfm/addisons_disease_in_dog
http://www.inmetrodetroit.com/pets/dachshund/frederick/addisons.htm
http://www.vetinfo.com/dencyclopedia/deaddisons.html
http://pets.groups.yahoo.com/group/AddisonDogs_/
http://canineaddisonsinfo.com/Support.html

How are things going for ya'll since we last heard from you?

You've done such a great job as an advocate for Aleah. Keep up the good work! I'm glad you found us and look forward to learning more about the both of you - and from you - in the future!

Hugs,
Leslie and the girls - always

[Dave Ruske]

Thanks, Leslie. Some of those I've seen, some are new to me. I've joined an Addison's discussion group on Yahoo, but haven't had much time to really dig into the research yet. Yesterday was pretty eventful for Aleah, though.

I returned from an early morning dentist appointment, and Aleah greeted me calmly. I didn't notice anything amiss until I walked to check in with my wife and Aleah didn't follow; she's usually shadowing one of us. I found Aleah in the living room, standing with her head lowered oddly, staring off into space. She was barely responsive and ignored a treat placed directly in front of her nose, which should've cost me a couple fingers. Her breathing didn't seem abnormal, but she absolutely did not want to move. She loves going for rides, but I had to carry her to the van.

At the referral center, the emergency vet found her reflexes to be okay, but she was still behaving dully and had a low fever (that spiked to 104.4 before dropping to 102 a couple hours later). Some blood work and a urinalysis later revealed that she had a bladder infection. They gave her an intravenous antibiotic and discharged her with 14 days worth of Amoxicillin.

I'm still not 100% convinced that the sudden odd behavior and her rapid return to normal was just this fever, but for now we know what we know. Maybe the fever gave her a nasty headache or something. Gave us quite a scare, though. My wife was crying; she didn't think Aleah would be coming back home.

While I was picking her up, the IMS had a chance to speak with me at length about Aleah's case. She'd posted details to an internist discussion board of some sort, hoping for some useful ideas. The board has 1200 members, but she only received 3 responses:


Respondent 1 suggested treating with mitotane. This would reduce a functional tumor, and if the remaining tumor tissue is benign we'd just continue treating for Cushing's. The internist is a concerned about what the other tumor tissue might do, though, and malignancy is a good possibility. With malignancy about 50/50 and tumors on both adrenals, it does sound like the chance of a malignancy is 75%.

Respondent 2 suggested doing nothing without more clinical signs. I don't feel this gives Aleah a very good life for very long, and the internist agrees.

Respondent 3 was the only one who'd actually treated a dog with bilateral tumors and had been in our shoes. Her response was blunt: "You're screwed." Not meaning that Aleah's case is hopeless, as I understand it, but that we aren't going to have any really good, low-risk options. In the dog this respondent had treated, they decided to remove the larger tumor and biopsy the smaller. It turned out to be a mistake: the larger tumor was non-functional, and the smaller was producing the excess cortisol.

Since we can't do much until Aleah's infection clears, the IMS is going to have the radiologist check a similar peer forum for input. She still thinks there's a chance that something like an MRI might provide non-invasive clues about what the tumors are up to. Come next Wednesday, we'll be taking Aleah in for a check of her infection as well as a second imaging of her adrenals to see if anything has changed since late November.

From there, I think surgery is likely, and unless we can learn more about the tumors through advanced imaging, I think a bilateral adrenalectomy will be necessary. Neither surgeon at this center has removed two adrenals in one surgery before, and I don't know how concerned I should be about that. I think I'll place a call to the University of Wisconsin in Madison tomorrow to see if I can determine how experienced their surgeons are.

Long as this message is, there's One More Thing. A couple weeks ago we noticed a growth in Aleah's mouth between the lip and gum on the lower left side. Actually, there are two growths, one on the gum, and one off a stalk on the lip, both measuring about 1.5 cm. Aleah's regular vet looked at this and said they didn't look malignant to him, so we decided to wait and see if we noticed any abnormal growth. The internist was a bit more concerned on seeing this, however, and wants to biopsy the one on the lip next Wednesday as it has an area of pigmentation. Supposedly, this is unrelated to everything else.

Tonight Aleah's pretty normal, playing, wagging, snugging and snoozing. I think I'll get off this silly machine now and just appreciate that for a while.

Thank you for your welcome and support, it is deeply appreciated.

Dave

[frijole]

Dave, I can't help re the adrenal tumors but wanted to offer support and say I am cheering you guys on! My gal Haley would every now and then have seizures similar to what you described. She didn't shake or anything she was just like frozen in a trance. It would last a while and then go away like it never happened.

Hang in there and I hope your internist is able to find some more cases to learn from. Kim

[Buffaloe]

Dave,

Here is a link to the ACVS website which will help you find the board certified surgeons in your area. It looks like there are at least a couple dozen in Wisconsin.

http://www.acvs.org/AnimalOwners/WhatisaBoardCertifiedSurgeon/

I'm glad Aleah is feeling like herself.

Hang in there and keep the faith.

Ken

[Dave Ruske]

Thanks, Kim and Ken. Kim: yes, we thought too it looked like some kind of seizure or perhaps even a stroke. The internist said that a malfunctioning adrenal gland can cause spikes in blood pressure, so maybe that played a role.

Ken, thanks for the ACVS link. I'll be emailing the surgeon at the referral center today to try and gauge his comfort level with performing a single or bilateral adrenalectomy, and I expect to call UW Madison later today to see if they have a surgeon that might be well suited to this task. I noticed that a good percentage of the board certified surgeons practice there.

We appreciate the support we've found here, and we hope things are going well for you and your dogs in return!

Dave

[Rebelsmom]

Dave, I don't know much about adrenal cushings since my pup has pituitary cushings. I just wanted to let you know that Aleah is a beautiful dog and we are keeping you and her in our thoughts. I hope you and your vet team can come up with the best way to deal with her tumors.

Lots of love.

[Dave Ruske]

We took Aleah in for more tests on Wednesday, and last night the internist called with a mixed bag of news.

The plan for Wednesday was to get an updated ultrasound to compare with last November, and give us a baseline for starting treatment; to biopsy the suspicious growth in her mouth; and to check the bladder infection.

We didn't do a follow up check on the bladder infection, because we'd been called the day before and told us that the culture had shown a bacteria that Amoxicillin wouldn't be too effective against, so they'd just started her on Cephalexin (2 week course, 500 mg every 8 hours).

I dropped her off that morning and received a call a bit later. They'd found several new spots on the liver, but these were hypoechoic --- something different than the original 1.3 cm hyperechoic mass. They asked if we'd like a biopsy, and we opted for a fine needle aspirate of both types of liver masses.

Besides the new liver masses, they found that the previously imaged liver mass had increased in size to 1.7 cm. The left adrenal gland had shrank to 1.36 cm from 1.55 cm, whereas the right had grown to 2.96 cm from 2.55 cm. That last is a concern, because the tumor is encroaching on the caudal vena cava, the largest vein in the abdomen. It hasn't invaded that vein yet, but it's close enough now to make surgery more of a risk.

Last night we received the biopsy results. The new hypoechoic masses on the liver are likely just side effects of the Cushing's and aren't worrisome. They hyperechoic liver mass does appear to be cancerous. The good news for that one is that it's a well-differentiated tumor which I am told should not be particularly aggressive.

The shocker was the mouth biopsies. They excised the 1.5 cm mass from inside the lip, as it was on a stalk and easy to take off. Another growth on the inside of the lip was more involved, but they took a piece of it. Both tested to be malignant melanomas. The internist said that until very recently the prognosis for this would be poor, but there may be a vaccine that will be effective against any stray malignant cells, after major growths are surgically removed. She's not certain whether this would work against the specific growths found in Aleah's mouth, but over the next few days we'll be consulting with an oncologist.

Aside from all that, I emailed the head of the surgical department at UW Madison's School of Veterinary Medicine to ask his opinion about the risks of a bilateral adrenalectomy in Aleah's case, should it come to that. He sent a very gracious reply over the weekend, but it was disheartening to read that the mortality rate for such a surgery would be 30-40%.

My wife and I have talked at length about all of this, and given the battle we're now fighting on 3 fronts, we don't think we want to put Aleah through the misery and risk of an adrenalectomy without a better prognosis.

While we're not deciding anything until we talk to the oncologist, here's what we're thinking we may do:


Surgery within reason to remove the melanoma in her mouth. If they need to do something like take half her jaw to take care of the melanoma --- something I'm told can be done --- we'd likely opt for palliative care. Use the vaccine, if feasible, to fight stray melanoma cells.


Try to shrink the adrenals with Mitotane. I need to talk more with the internist, but the way I interpret the one gland shrinking and the other enlarging is that the right gland is producing cortisol and suppressing those cells in the left gland --- meaning tumors on both glands are, at least in part, responsible for cortisol production. Those are the types of cells that Mitotane kills off, as I understand it. If the tumors respond as I hope, that should bring her Cushing's under control as well as keep the right gland from intruding on that critical vein.


If we are blessed enough to have success treating those two more pressing issues, we'll consider surgical removal of the cancerous mass on the liver, which should be easy to get to. Whether or how long we can wait for this surgery will depend a lot on what the oncologist tells us this week.

Today is January 22nd, exactly two months since Aleah's first ultrasound showed us the adrenal tumors, and the first time I'd heard of Cushing's disease. What a crazy ride. Meanwhile, Aleah is basically her happy-go-lucky self, but is probably wondering why on earth the people who care for her would have her belly shaved just in time for the coldest weather Wisconsin has seen in two years.

Hope you and your pups are all doing well, and fighting the good fight.

Dave

[marie adams]

Hi Dave,

So many decisions to make, but I know you will make the right ones for Aleah.

My Maddie possibly had an adrenal tumor, never did the ultra sound or extra tests to confirm just wanted to help her symptoms get under control. We did pretty good once I came to this site for help in the beginning, but the cancer ended up doing the damage in the end--it went too fast for us.

Take care of yourself--the roller coaster goes all over the place, but everyone here is such a comfort and knows their stuff or will find it for you!!!!:)

[Buffaloe]

Dave,

Burrrrr, I know it is really chilly up there in Wisconsin. Maybe Aleah needs a little sweater type thing to keep her tummy warm. I won't tell you what it's like in Phoenix now, but right after I send this post I'm going to go for a long bike ride in shorts and a tee shirt. But in the summer when it is gorgeous up there, we're dealing with 110 degrees many, many days.

Your deep love and concern for Aleah is crystal clear. With only a 65% success rate for the bilateral adrenalectomy (hope I got that right) I sure do understand your decision not to proceed with the surgery. As you know, it is a very big surgery for a dog.

I'm glad to hear the original mass on her liver is not aggressive and that the others appear to be innocuous.

Your upcoming discussions with your Internist and Oncologist should prove very insightful regarding the adrenal tumors and Lysodren treatment. Let's close our eyes and visualize the Lysodren kicking the cra* out of those tumors, similar to what the Packers are going to do to the Bears tomorrow.

I think you are exactly right to focus on the melanomas in Aleah's mouth. I'm sure you will receive great information from your professionals about how to proceed.

Dave, it puts a huge smile on my face knowing that Aleah is feeling so good now and is her happy-go-lucky self. That is gigantic. Take full advantage of that sweet girl all throughout every day. You are doing a phenominal job with Aleah. I guess, bottom line, you get all the information from your top professionals and then go with what your gut tells you is best. I know you will make the right decisions for precious Aleah and she is in my thoughts and prayers.

Ken

[Dave Ruske]

Thanks, all, for your support. I'm not sure this is the right forum at the moment, as the Cushing's treatment has taken a back seat to the melanomas, but I thought I'd update anyway.

Aleah and I had our visit with the oncologist this morning. She agreed with the internist that the liver tumor was the least of our worries and could be treated later, and we learned nothing new about the adrenal tumors... except that my theory that the shrinkage of one might suggest functionality that would respond well to Mitotane might be a bit optimistic. It isn't ruled out, but we won't know until we try therapy.

But that needs to wait until the melanomas are dealt with. Without treatment the melanoma will likely claim Aleah within a few months.

We talked at some length about a mandibulectomy, which would take about half of Aleah's jawbone with the remaining tumors in her mouth. There was also the possibility of radiation therapy, but that carries a smaller chance of success. In either case, we'd follow up with a melanoma vaccine that's become available in the last few years.

I scheduled an appointment with their dentist for Thursday morning, and if after that consultation we want to go through with the surgery, they'll do it in the afternoon.

The decision weighs on me tonight. Intellectually I know there's something malignant and destructive in our dog that will kill her; but as I write this I have a happily ignorant fuzzface nudging my elbow for a little scratch behind the ears. With all her problems, I wonder how long she has, and whether I'll make her remaining time miserable with the path I choose.

I'll be reading up on mandibulectomies, particularly testimonials of people who've been through them with their dogs. I suspect some of my agonizing is really just me expecting a dog to react like a human --- lots of fretting and sadness over the way things were. Dogs live for the moment, which is something I guess I could learn from.

Dave

[StarDeb55]

Dave, I have not posted to you before as I have no experience with adrenal tumors, but I do have experience with facing an almost impossible decision in the treatment of our pups. My first cushpup, Barkley, had been doing well with his Cushing's for about 6 years when he became very ill. To try to give you the short version, after running back & forth between my GP vet & derm vet for 2 weeks, with no conclusive answers, we were sent to an IMS. The IMS diagnosed lymphoma. At the age of 13 with already many years of multiple medical problems, I initially did not want to put B through anything else. I went ahead with an oncology consult, & when I heard that with not treatment, B could be gone in 6-8 weeks, & we had already wasted 2 weeks, I really became frantic. After a very long discussion with the oncologist, I opted for chemotherapy. I really was worried sick as I work in the hematology lab in a major hospital, so I know what chemo does to people. B's & my fairy godmother was sitting on our collective shoulders when I made that decision. The chemo bought B another 20 months with a wonderful quality of life. He crossed the bridge at 15.

I saw a will to live in B that I don't think I had ever seen in any of my other pups over the years. From the way you talk about Aleah, I can almost see that she appears to have that same will to live. I know contemplating the type of surgery that will have to be done to save her life is almost horrifying in nature, but I know you will make the best decision for both of you.

Debbie

[Squirt's Mom]

Hi Dave,

A few links for you...computer acting up...gotta run....will look for more later....prayers and healing white light for you and Aleah....

http://www.acvs.org/AnimalOwners/HealthConditions/SmallAnimalTopics/MandibulectomyandMaxillectomy/

http://www.petplace.com/dogs/mandibulectomy-in-dogs/page1.aspx

http://veterinarymedicine.dvm360.com/vetmed/Medicine/Prognostic-factors-and-complications-associated-wi/ArticleStandard/Article/detail/601626

http://www.jaaha.org/cgi/content/abstract/33/1/25

http://www.mypetsdentist.com/site/view/114761_MajorOralSurgeryConcerns.pml

http://www.curehunter.com/public/pubmed1369522.do

[labblab]

Thanks, all, for your support. I'm not sure this is the right forum at the moment, as the Cushing's treatment has taken a back seat to the melanomas, but I thought I'd update anyway.

Dave
Dear Dave,

I've not had the opportunity to reply to you before this, either. But even though I'm late to enter the scene :o, I want to encourage you to remain with us, regardless of the treatment challenges that you face with Aleah. As was the case with Debbie and her Barkley, many of our members have experienced health issues in addition to Cushing's. And even though we may not have a lot of knowledge about them all at the outset, we are eager to learn right alongside you (as you can see from Leslie's reply -- thank you, Leslie! ;)). You and Aleah are members of our family. And we will remain anxious to hear updates, and we will do our very best to provide as much support and feedback as we possibly can. So unless it should feel burdensome to you to keep us in the loop, please don't leave us!

Sending healing hugs to your sweet girl,
Marianne

[addy]

Hi Dave,

Did you see this morning's article on the veterinary school in Madison? They have a new clinic with radiation machine that can target the tumors exactly. It is in the Journal Sentinel.

Thought it might be of interest to you.

Also wanted to say hello to a fellow Wisconsinite:D

Addy

[Dave Ruske]

I really appreciate the support here, and thanks for those links on mandibulectomies. Some of those I'd seen, but that last one I definitely hadn't. I would've remembered this bit:


"...Based on survival curves, 37 dogs with a melanoma had a median survival time of 9.9 months (range, 1 to 36 months), with a 21% 1-year survival rate; 20 dogs died or were euthanatized for recurrent or metastatic disease..."

That seems like some pretty harsh surgery to put Aleah through for that kind of an outcome, but it's no misprint; the oncologist gave some similar statistics. Much of what I've read on the web suggests that dogs do adjust fairly well to losing part of their jaw, but given the odds we're up against, we just can't put her through it.

Radiation might be a good compromise. The oncologist said that melanomas respond well to radiation therapy, with 80% seeing tumor shrinkage and perhaps as much as 70% seeing complete shrinkage. (I hadn't seen that Journal-Sentinel article, Addy. Interesting timing, as I'd just emailed a radiation oncologist at UWM today... I hope she's not too swamped with inquiries now to reply!)

We're not giving up on Aleah, but realistically, adding up all her issues, we know she's unlikely to be with us by the year's end. With that in mind, we've decided to choose treatments based foremost on her comfort. We'll fight, but gently, so that the time we have with her can be remembered well.

[Squirt's Mom]

We'll fight, but gently, so that the time we have with her can be remembered well.

A plan based on love, sure to succeed as a result.

Hugs,
Leslie and the girls - always

[Bichonluver3]

Hi Dave!
I really can't offer advice as Chloe has atypical (PHD) Cushing's but the folks that do know will stay right beside you as we all will. Lots of healing thoughts, prayers and energy are being sent from our house to yours. You have done everything right and are a true advocate for Aleah. Please keep us posted. We are following your thread closely.
Love & hugs,
Carrol & Chloe

[Dave Ruske]

After talking with the dentist Thursday and sharing our concerns about the mandibulectomy, she suggested that we might be able to get by with excising the soft tissue melanomas and taking just a small amount of bone with the nearby premolars. It sounded like a surgery that had a fair chance of success without compromising Aleah's quality of life for more than two weeks, so Aleah had the surgery that afternoon.

Thursday night she was already up to eating a little canned food mixed with water. Friday she was obviously sleepier and slower than usual, but went through a couple cans of food. By Sunday she was her happy self again, wagging, rolling over for belly rubs, and searching madly for the fluffy squeaky toys we have to hide while her mouth heals. She's doing great, now, though we still have to put the Cone of Shame on her head when she's unsupervised to keep her from pawing out a suture.

More good news arrived today: the dentist called and said that the bone from her jaw tested negative for melanoma! :)

Despite the conservative approach to the surgery, it appears to have been successful. Melanoma's a bugger to get rid of, and we haven't forgotten the survival stats, but we're hopeful that the vaccine will take care of anything remaining. The vaccine is still fairly new, so perhaps the odds have improved. In any case, I think we've done as much as we can do about it, so the rest is God's choice.

I expect we'll start medicating for the adrenal tumors in the next week or two. The IMS gives preference to Mitotane, because it has a chance of actually shrinking the tumors, and with the right tumor edging in on the vena cava, shrinking that tumor sounds like a very good idea. I've heard anecdotal evidence that many dogs with adrenal tumors have experienced good quality of life with Trilostane, but I need to do some reading this weekend to try and figure out the pros and cons of each drug for Aleah's case.

Dave

[Bichonluver3]

Great news about the dental surgery, Dave. :D
It also sounds as if you have a good option for the adrenal tumors. Our Aleah is a little trouper and God IS watching. Just wanted you to know we are watching for updates and are sending all our love, energy and support your way.
Carrol & Chloe

[Dave Ruske]

Thank you, Carrol and Chloe, we appreciate your support!

Dave

[Sabre's Mum]

Dave

Fantastic news about Aleah's surgery and the results from the bone biopsy! All the best with your decisions with regards to medical treatment. Keep us updated and if you have any further queries ... ask away.

Angela and Flynn

[AlisonandMia]

There may be a third treatment option and that is ethanol ablation. I have no idea if your drs could offer this but it could be a possibility. Here's a link to a thread where a dog underwent this treatment. Unfortunately in this case it didn't seem to help (probably metastases producing hormones elsewhere in the body) but it does sound like it could be helpful in some cases: http://www.k9cushings.com/forum/showthread.php?t=597&page=6 (She didn't suffer any ill effects from the procedure however as I recall.)

Here's a link to a human case report outlining a successful use of this treatment in a human: http://www.ajronline.org/cgi/content/full/174/4/1031

I would suspect that with bilateral tumors that you would run the risk of a inducing an Addisonian state with this treatment and it may not even be an option with bilateral tumors.

Alison

[Squirt's Mom]

Hi Dave,

What great news to read this morning! :D It really thrilled me to hear you talk of her wanted to play with her toys. Our babies are so amazing, huh?

Try to forget about statistics and just believe....miracles do still happen and the ones I've seen were fueled by an intense love - a love Aleah most certainly knows.

You are doing an amazing job on Aleah's behalf! Keep up the good work...

Hugs,
Leslie and the girls - always

[Bichonluver3]

Good morning, Dave!
Leslie is right - miracles DO happen and, usually when we least expect them. Just wanted you to know we are thinking of you.
Love,
Carrol & Chloe

[addy]

Hi Dave,

Glad to hear the surgery went well for Aleah. Hope you survived the "Blizzard" and are hunkered down with your pup today enjoying a snow day.:)

You have done an amazing job with your research. Aleah is so very lucky to have you fighting for her.


Hugs,
Addy

[Buffaloe]

Dave,

Great, great news about Aleah's surgery!!! It sounds like she is doing as well as could possibly be hoped for at this point. She's gonna have years to play with her toys once she's all healed up.

As far as the Lysodren/Trilostane question, it probably just depends on who you talk to. You have some time before you have to make your decision. Also, whichever one you choose, if you're not seeing the results you hoped for you can switch to the other. I think the book says there's a 30 day wash out period but I they shorten it sometimes when dealing with adrenal tumors.

Buuuurrr. 'Hope you and Aleah are staying warm.

Ken

[Dave Ruske]

Thought I'd check in quick. Aleah's mouth is healed up nice with no signs of additional melanoma, and she's a happy girl now that she's shed the cone and can play with her toys. She took the first melanoma vaccine injection with no complications and goes back for the second on Wednesday.

I have a prescription for Mitotane and we'll be starting the induction late next week. The dosage prescribed is 1500 mg per day for loading, which jibes with the documentation I've found for treating ADH (50-75 mg/kg/day). We've started dividing Aleah's meals into 3 per day to get her used to the schedule, and plan to give 500 mg following each meal, probably in peanut butter (the fats will help the absorption, and Aleah loves her peanut butter; may as well make it fun for her).

Because Aleah's clinical signs aren't real obvious, the IMS is thinking about prescribing a low dose of prednisone or dexamethasone to avoid any catastrophic drop in steroid levels. Dexamethasone might be preferred as it shouldn't interfere with the ACTH stim test when we think we're at the end of induction, so I'm told, but she's gathering her thoughts on it over the next few days.

Here we go...

Dave

[By the way, Alison mentioned ethanol ablation as a possible treatment; I did check into that (thanks!), but the oncologist said that it's not a procedure they've tried, and she hadn't seen it done during her rotation at UW Madison, either. There's not much out there that I could find, so I think we'll put that thought aside for the moment.]

[Dave Ruske]

We're at the end of day 3 of Mitotane loading at 1500 mg/day, and so far no ill effects, change in appetite, or change in behavior. So far, so good. We're giving her 10 mg of Pepcid half an hour prior to the morning and evening meals to help prevent an upset stomach.

The IMS decided to go without the low dose of prednisone or dexamethasone, at least for the loading period. We do have some prednisone on-hand for an emergency, with instructions to contact the vet and administer 7.5 mg per day.

Unless Aleah shows some sign that induction is over, we'll be taking her in on Friday for an ACTH stim test.

[AlisonandMia]

I'm so glad that you've opted out of the concurrent dosing with pred or dex! That is actually very often a recipe for, if not disaster, certainly trouble. You really want to be able to see either loading signs or at least signs that the cortisol is going too low. Concurrent steroid meds mask that and going on dosing with Lysodren after the adrenals have ceased to be able to make cortisol can result in destruction of their ability to produce aldosterone - which is a really vital hormone as it is what regulates the potassium/sodium balance in the body.

Having pred or similar on hand is a must however.

I suspected that alcohol ablation wouldn't be an option. It seems to be just appearing on the horizon in vet medicine and it is certainly something that would need to be done by an experienced operator - presumably the few that do offer it have learned how to do it from human doctors.

Good luck with the loading and keep us posted!

Alison


Alison

[Dave Ruske]

We're only midway through day 5 of induction, and Aleah definitely paused twice during her afternoon meal and ate a bit more leisurely overall. She still finished all her food, though, and licked the bowl afterwards.

That seems like a really subtle difference to us, but our understanding is that the signs of the end of the Mitotane induction can be pretty subtle. So rather than give her the Mitotane dose after the meal we placed a call to the IMS, and we're waiting for a call back. I suppose the worst that can happen is that the IMS will tell us we're paranoid kooks, or that we'll end up doing a premature ACTH stim test. Either outcome seems better than overdosing.

Alison --- yeah, the concurrent prednisone or dex had me concerned, too, about masking the loading signs. And if the signs really turn out to be as subtle as what we've seen today, it wouldn't have taken much to mask them!

Dave

[Dave Ruske]

Hmm, well, it seems we're not going in for subtle. I've read a number of stories here and elsewhere about treating Cushing's, and I guess I'd calibrated my expectations around those experiences.

Treating Cushing's is only part of the game plan with the Mitotane, as the IMS explained to me. In Aleah's case, we actually want to try and kill off the adrenal tumors. While the IMS did say that she wanted me to contact her if Aleah shows more severe signs or if the inappetence becomes more significant, the likely course is that we'll use prednisone to counteract the effects of the Mitotane. Unless something more severe happens in the meantime, we'll continue the loading dose until an ACTH stim test planned for Monday.

Just taking it a day at a time...

Dave

[AlisonandMia]

Hmm, well, it seems we're not going in for subtle. I've read a number of stories here and elsewhere about treating Cushing's, and I guess I'd calibrated my expectations around those experiences.

Treating Cushing's is only part of the game plan with the Mitotane, as the IMS explained to me. In Aleah's case, we actually want to try and kill off the adrenal tumors. While the IMS did say that she wanted me to contact her if Aleah shows more severe signs or if the inappetence becomes more significant, the likely course is that we'll use prednisone to counteract the effects of the Mitotane. Unless something more severe happens in the meantime, we'll continue the loading dose until an ACTH stim test planned for Monday.

Just taking it a day at a time...

Dave


Most of the stories you have read - and the standard protocols - are about treatment of pituitary Cushing's. Adrenal Cushing's is a different disease, really, and sometimes the aims of treatment are different the results are nothing like as predicable.

My biggest concern would be not that her cortisol will go too low - that can be remedied quickly with prednisone - but that too much mitotane could affect her ability to produce aldosterone. It is reducing aldosterone levels to the point that the electrolytes get out of whack that is the biggest danger with treating Cushing's of any kind. Both mitotane and trilostane can have this effect in overdose. This electrolyte imbalance is what can kill and it is a medical emergency if it happens.

From what I have read regarding treatment of human adrenal tumors with mitotane what is often done is that large doses are given in an attempt to impact the tumor as much as possible and then meds are given to make up for deficient cortisol and maybe aldosterone if necessary. It sounds like this is what your IMS is aiming for at least at this stage of treatment. My feeling is that as long as the dog is monitored and given rescue medications as necessary your IMS's approach could well be a very good one and could give the best quality of life for the longest time. Are you going to follow up with other ultrasounds to see how the tumors look?

With adrenal Cushing's I think in the past here we have only ever seen mitotane being used strictly palliatively with the aim to improve quality of life by reducing cortisol and maybe inhibiting tumor grown (hopefully). When it is done this way the aims of treatment are very similar to the aims of treatment with PDH. However, I have noticed (and this is just my amateur observation on a pretty small sample!) that many dogs with adrenal tumors seem do better with the cortisol on ACTH stim considerably higher than do PDH dogs. PDH dogs (on mitotane) do best somewhere between 1 - 5 whereas a lot of adrenal dogs seem to do best with their cortisol somewhere around 7 - 10 or even a shade higher.

How responsive a tumor is to mitotane seems to have to do with the makeup of the tumor. Some seem to be totally unresponsive - they are just totally impervious to the stuff but on the other hand I have read of one case (in the published literature) where a dog's tumor vanished completely with mitotane therapy - even though that wasn't the aim at the outset as far as I know. (I'll try to find it again.) I've only ever heard of that one case though and it certainly isn't what anyone expects or even dares to hope for when starting treatment. Most tumors seem to be somewhere in between the two extremes.

I so hope that Aleah's tumors are mitotane-responsive - the fact that you are possibly seeing signs bodes well, I think.

Do you have access to emergency care throughout the weekend?

Good luck and keep us posted?

Alison

[Dave Ruske]

Alison, thanks so much for your very informative post. I need to read up on aldosterone. I don't know how low aldosterone or fouled electrolytes manifest, but I'm betting it's covered in the instructions from the IMS:


Signs of overdose are weakness, lethargy, vomiting, diarrhea, collapse, or neurologic signs... If she is weak, lethargic, or collapses, she should come to the ER immediately.
Your message also explains why, when we do bring her in for testing, it will be for "an ACTH stimulation test and renal panel (electrolytes)." From the outset, the IMS also said she'd like to run another ultrasound a month or two after starting treatment. Overall, it sounds like she's on top of things.

We are fortunate to live less than 20 minutes from the Wisconsin Veterinary Referral Center, which has ER staff 24/7. As long as the roads aren't a snow covered mess, we can get Aleah there pretty quick should something go wrong.

Dave

[frijole]

Dave, I just wanted to check to make sure you have prednisone ON HAND in case of a crash. Driving to the ER would still be necessary but phoning the vet/IMS and getting permission to give the prednisone would be my first priority. It can give relief fairly quickly. Kim

[Dave Ruske]

Yes, we do have prednisone if needed. We'd do exactly as you say: contact the vet then give the prednisone as directed.

Thanks!

Dave

[frijole]

:) No problem and you probably won't need it but better safe than to assume. Best of luck and hugs to Aleah. Kim

[Buffaloe]

Dave,

You and Aleah have a big time cheerleader here in Phoenix. I'll be praying that the Lysodren works beautifully for Aleah. You are truly doing a fantastic job for your sweet girl.

Ken

[Dave Ruske]

Thanks, Ken... prayers may be our best bet!

Dave

[Bichonluver3]

Hi Dave!
Lots of prayers and support from us in the California desert. Yes, the answer is one day at a time and, somehow, those days just roll on by. I think you are an amazing dad and with you (and all of us:D) on her side, I am sure Aleah will get her problems resolved.
In the meantime, know that we are standing beside you in spirit and give that special girl a big old tummy rub from us.
Love,
Carrol & Chloe

[Dave Ruske]

Thanks Carrol... and Chloe!

We just wrapped up day 7 of mitotane induction at 1500 mg/day.

Aleah hesitated with her meal this morning, so I withheld the mitotane and checked in with the IMS. She suggested that we try running the ACTH stim, though I'm not certain whether she truly thought it was necessary or just wanted to put my anxiety to rest. So test we did, and here are the results:

ACTH stim: base line 4.9 µg/dL, 1 hour 17.7 µg/dL. The IMS wants the 1 hour value below 5 µg/dL. Standard practice, from the little I've read about the test.

The renal panel numbers all looked solid:

Urea N at 17 mg/dL (ref. range 8-30)
Creatinine 1.2 mg/dL (ref. range 0.5-2.0)
Phosphorous 3.8 mg/dL (ref. range 2.5-7.9)
Calcium 10.6 mg/dL (ref. range 8.7-12.0)
Sodium 151 mmol/L (ref. range 141-159)
Potassium 4.3 mmol/L (ref. range 3.4-5.6)
Chloride 106 mmol/L (ref. range 100-118)
Bicarbonate 30 mmol/L (ref. range 16-31)
Anion Gap 19 mmol/L (ref. range 15-25)
Albumin 3.7 g/dL (ref. range 2.6-4.0)

While I'm glad the numbers look good, I know now that I can't count on slight inappetence as a sign that induction is over. And, of course, I'd much rather have seen ACTH results that told us we were at the end of induction and could relax a little more. But apparently even her tumors have a farm collie's grit and won't go without a fight.

The next ACTH stim test and Aleah's next melanoma vaccine booster are scheduled for Wednesday, if nothing weird happens in the meantime.

Dave

[AlisonandMia]

Hi Dave,

Did you do a stim test before starting treatment? If so, what were the numbers from that test?

Alison

[frijole]

Dave,

My Haley took forever to load. She had 90 days of loading (doesn't count the days off for acth testing and waiting for results). We kept increasing the dose as well. She didn't drink abnormal amounts of water so food was my only way to monitor... and I too lost that symptom prior to her being loaded... so I took up "Poop Patrol".

Since diarrhea is a sign of too much lysodren I started monitoring the firmness of her poops with a stick. Yes, quite fun in the dark with a flashlight in the winter in snow.... :p Anyway, it worked. It slowly got less firm. Never got runny. I just went with my gut and when I had her tested she was at 1.8. I hope this helps. Not an exact science but it gave me peace of mind.

Kim

[Dave Ruske]

Alison, while Aleah has been through a lot of diagnostics tests, yesterday was her first ACTH stim.

Kim, 90 days of loading... wow! I had no idea induction could last that long.

Dave

[frijole]

Kim, 90 days of loading... wow! I had no idea induction could last that long.

Dave


:D It can't and doesn't... only my gal Haley. She holds the record. Alison's dog is in 2nd I think. We are overachievers. ;)

[Dave Ruske]

This would have been day 12 of loading on mitotane, but yesterday Aleah was blasé about her food, and this morning she showed even less interest, so I didn't give the mitotane and called in to the IMS around 8 a.m. As of 12:30 p.m., I still hadn't heard back, and decided to give 7.5 mg of prednisone. We then went on a walk and she seemed pretty good. She's having some difficulty jumping up on the bed today, though.

At 2 p.m. I tried feeding Aleah again, and she still had no interest in eating. My wife is in the kitchen now trying to coax her to eat something, without much success. I called the referral center again and they said they'd have the IMS call me when she returns from lunch; apparently she's had quite a busy morning.

I'm not sure at this point whether I'm taking this mitotane induction too seriously or the IMS isn't taking it seriously enough, but I'm finding the gap rather frustrating.

Aleah's results on the ACTH stim and renal panel looked solid on Thursday; could they be radically changed in just a few days time?

Dave

[lulusmom]

Hi Dave,

Without establishing a baseline cortisol before loading, there's really no way to tell how far the cortisol had dropped on the first stim. Aleah's post number was 17 ug/dl and if it had been 30 ug/dl before loading, then you'd have to assume that the drop was pretty substantial. Plus, keep in mind that you had the stim done less than 24 hours after the last dose of Lysodren. The drug continues to accumulate for at least 48 hours after the last dose so that means the 17 ug/dl would have been lower had you waited until the next day. There is no way to know for certain but we've seen it all here so I wouldn't be shocked if Aleah's post cortisol is down in the mid to low single digits.

Glynda

[Dave Ruske]

I wish I'd have thought to ask about running a baseline before we started treatment. Hopefully the IMS had a good reason for not doing that.

I still haven't heard anything back, so I called Aleah's family vet. He said that we probably didn't need to give the prednisone at this point, but thinks we were right to stop the mitotane. I'm not sure the IMS will agree with that, as my impression was that she wanted us to plow ahead with the mitotane and give the prednisone concurrently once we started seeing a loss of appetite or weakness, but the paperwork she gave me says "If at any time you are concerned with the treatment it is best to stop the treatment until you speak to us."

Well, I'm concerned, and I've sure made every effort to speak with her today, so I'm not entirely off the map.

Anyway, the family vet says with the mitotane stopped, we shouldn't be facing anything dire at this point, but to call it in if we see more serious symptoms develop.

Dave

[lulusmom]

Hi again,

Are you sure your IMS wants you to continue giving lysodren with prednisone when Aleah quits eating or gets weak? That is really, really scarey. In Europe, it is an accepted protocol to intentionally and completely destroy the adrenal cortex because it is thought that an Addison's dog is much easier to treat. The problem with that is twofold. First, it's a very risky proposition, which is why it's not done here in the states, and secondly, the adrenals will regenerate in a good number of dogs and at some point you'll be right back where you started. The adrenals are tough cookies and unless you kill every single cell, they are going regenerate on you. Honestly, if your IMS is advocating this risky approach and is not making herself or an alternate available to you in the event of an emergency, I would be livid and looking for another specialist. Honestly, your gp vet sounds like he has a lot more sense.

Glynda

[Dave Ruske]

I wasn't 100% certain the IMS wanted the prednisone administered concurrently with the mitotane, though I know that is what I was told last week. It didn't feel right, though; I kept thinking I must have misunderstood. The only thing I have in writing about the prednisone reads:


Wait to give the prednisone until development of concern for Lysodren complications. Lethargy, weakness, or loss of appetite are indications to start it once daily. Avoid giving it within the 24 hours before the scheduled ACTH stimulation test as it will interfere with results. Notify our office when you begin giving this medication. If symptoms persist despite giving the prednisone treatment, contact our office as Aleah may need to be seen.
It doesn't explicitly say to stop nor to continue with the mitotane. It seems to me that a need to start prednisone would indicate a need to be seen and tested, though.

The IMS finally did call back just before 5 p.m., and told me that a mistake was made and she didn't see the note from 8 a.m. until she'd received the note from my 2 p.m. call. Even so, a 3 hour response time doesn't make me particularly happy.

In any case, we've suspended mitotane and prednisone and will be bringing her to the referral center at noon tomorrow for a second ACTH stim test. I'll likely post the results some time tomorrow night.

Dave

[lulusmom]

Hi Dave.

I'm sure I won't be the only one waiting for the results of Aleah's stim test.

Glynda

[marie adams]

Hi Dave,

I am so sorry for all your frustration with the vet. I felt like I wanted to kill them for all they - 3 of them total or maybe it was their staff--3 different offices. It seems like they just didn't care. I realize I was not their only patient, but still how many times does it take to get the vet a message to have them call you back--well with my 2nd vet it took 3 days to get an ACTH test back--just plain frustrating.

I am so scared for the next go around with a puppy--who do I trust after everything Maddie had to go thru in the end because of my stressing out just to get results for which I paid an absolute fortune for.

Sorry for the venting but it just isn't fair to you and Aleah to have to go through this; you are already stressed and this just adds to it. I learned that you get better answers here with everyone who has gone through this--I didn't always follow what the vets said, but I did follow what the members said--haha just a rebel...:D

I hope everything goes well tomorrow and Aleah starts feeling better. :)

[Dave Ruske]

Good news! Well, mostly, anyway. We think Aleah might have a bladder infection --- her water intake went up quite a bit over the last few days, while her appetite decreased. We started her on an antibiotic (cephalexin, 1500 mg/day) while we're waiting for the culture results.

Aleah's ACTH stim showed a base value of 1.6 µg/dL, and a 1 hour value of 7.0 µg/DL. While a 1 hour value of 5.0 would have been ideal, we didn't give the mitotane yesterday. The IMS suggested we start her on a maintenance dose of 1500 mg twice a week, and we'll perform another ACTH stim in 3 or 4 weeks to see where we're at. We'll probably do an abdominal ultrasound at the same time to see if we're actually reducing the size of the adrenal masses.

Renal panel numbers still look great:

Urea N at 15 mg/dL (ref. range 8-30)
Creatinine 0.8 mg/dL (ref. range 0.5-2.0)
Phosphorous 3.2 mg/dL (ref. range 2.5-7.9)
Calcium 10.6 mg/dL (ref. range 8.7-12.0)
Sodium 150 mmol/L (ref. range 141-159)
Potassium 3.8 mmol/L (ref. range 3.4-5.6)
Chloride 106 mmol/L (ref. range 100-118)
Bicarbonate 30 mmol/L (ref. range 16-31)
Anion Gap 18 mmol/L (ref. range 15-25)
Albumin 3.6 g/dL (ref. range 2.6-4.0)

Aleah didn't want to eat at all this morning, but ate half her meal this afternoon. I took a handful of kibble and loaded up this plastic ball that dispenses treats as she rolls it, and she ate every bit of that. Same food, but more fun that way I guess, the spoiled brat.

Tomorrow morning she gets her third dose of melanoma vaccine, and then, hopefully, no more vet visits for a few weeks.

Overall, a pretty good day, and reason to hope.

Dave

[SachiMom]

Hi Dave,

Although I haven't posted to you before, I have been following Aleah's journey. She is amazing!!! With an amazing Dad!!!! And we can always use the good news. Everyone does the happy dance after a successful load . . . so everyone . . . one, two, three . . .

I just wanted to be sure that someone (with alot more knowledge than me) checked your maintenance dose. I thought the usual maintenance dose ended up being the daily dose spread over the week. But perhaps they want to get the post number down a bit more? or the higher dose is because of the adrenal tumor?

Hope the third melanoma vaccine goes off without a hitch.
Sending healing thoughts and prayers.
~Mary Ann

[Dave Ruske]

Thanks, Mary Ann.

Good point about the dosing. I checked the dosing information for ADH that I'd found, and that indicates maintenance of 75-100 mg/kg/week. For Aleah, that translates to 1838 to 2450 mg/week, so 2000 mg/week would seem a more likely dosage.

As you said, the IMS may have went heavy due to the high post number, but I'll double check the dosage when I bring her in for her vaccine in a few hours. We hadn't planned on the next dose of mitotane until tomorrow, so I have time to check in to this.

Dave

[Dave Ruske]

Hi, all. Thought I'd check in with some news, now that I have some. I'm sorry to report that the news is not good.

For quite some time I've commented here about how Aleah's appetite seemed off. The timing of this corresponded with the mitotane treatment, so naturally we were thinking that was the cause. Generally, with some coaxing and bribery, we were able to get her to eat, but it gradually worsened. The mitotane was stopped, and the daily prednisone was bumped from 7.5 mg/day to 10 mg/day, to no avail. 10 mg Pepcid twice daily also had no effect.

Yesterday she showed almost no interest in food nor water, so I took her in again. Everything seemed fine on physical examination, and no fever was present. Given that her recent ACTH and renal panel looked good, the doctor asked if I wanted them to run a broader spectrum of tests to see if anything would turn up (CBC and chemistry panel). Something did.

This morning the vet called to tell us Aleah's liver had failed, or was very close to it. I had her FAX the paperwork to me. ALT was 2912 IU/L (reference range 12-118), and alkaline phosphatase was 6659 IU/L (reference range 5-131). Also high were AST (466 IU/L, normally 12-66), GGT (65 IU/L, normally 1-12), total bilirubin (1.4 mg/dL, normally 0.1-0.3), and cholesterol (662 mg/dL, normally 92-324). The lab had marked the ALT, alkaline phosphatase, and GGT numbers as "result verified."

The vet told us that all we can do now is keep her comfortable and try to get her to eat some boiled hamburger. Aleah did eat and drink a little this morning, but mostly just wants to sleep.

I can't say that I would have done things any differently; I made what I feel were the best decisions I could each step of the way, based on what I knew at the time. We got her past oral melanoma, and I really believed we were beating at least the symptoms of the Cushing's if not the cause. The liver mass was thought to be a hepatocellular carcinoma based on a fine needle aspirate, and wasn't expected to be a near-term problem.

Maybe the liver mass wasn't what it was believed to be, or perhaps an adrenal tumor or the melanoma metastasized to the liver, or maybe the combination of the Cushing's and the drugs were too much for the liver to handle. I don't know, I didn't even ask; it doesn't really matter. I don't believe there's any reason for further tests.

Aleah will beat this, by going where disease and suffering cannot follow, and she will leave with as much love as a dog could ever hope for.

Thank you all for your love, prayers, and support; may it be paid back to you tenfold. Give your pups a hug from us.

I'll check in again soon.

Dave, Kit & Aleah

[Squirt's Mom]

Dear Dave and Kit,

Aleah has certainly had the best chance to beat anything that has been sent her way with you as her parents. You have fought every battle with courage and love. I'm convinced Aleah has been able to face each challenge because she has ya'll by her side.

Please know we are here anytime should you wish to talk.

My thoughts and prayers are with you all.
Hugs,
Leslie and the gang

[Harley PoMMom]

Dear Dave and Kit,

My boy, Harley, is in liver failure also. I had asked my vet about using ursodiol, which is a medicine given to dogs with liver disease. We couldn't with Harley because ursodiol shouldn't be used if a dog has pancreatitis, which Harley does.

My thoughts and prayers are with you all.

Love and big hugs,
Lori

[addy]

Dear Dave and Kit,

I am so sorry to hear this news. You have been amazing with your support for Aleah. I know you will continue to cherish each day you have with her.

My heart goes out to you.

Hugs,
Addy

[frijole]

Dave and Kitt - Although this is tough news to swallow, your attitude alone will get you thru this. Aleah is one lucky dog. No doubt you guys have done everything possible. Sit back and enjoy every single remaining minute. Give dear Aleah hugs from all of us. Kim

[marie adams]

Oh Dave,

How I know what you are going through. You have such a good attitude for Aleah.:) I cherished as much time as Maddie and the family had together. We are all here to help or give you support. :o

[Dave Ruske]

Thank you, everyone, for your kind words of support.

Aleah left us peacefully yesterday during a home euthanasia, with my wife and I stroking her fur and giving her love until the final beat of her heart. Her departure marked the end of a week filled with both tears and laughter as we recounted her antics of the past 6 years. We spent this last week spoiling her to the best of our ability, and she was able to enjoy a couple short trips to a nearby park, even a pleasant hike on her final morning. Though she ate and drank little, we cooked up beef, chicken, and bacon for her and she had the thrill breaking a taboo and licking off dinner plates.

I've added four new photos to the dozen posted here (http://gallery.me.com/ruske#100016); the four at the end are from our last week. They are anything but sad; they are images of a time we'll always cherish.

There is more to Aleah's last week, though, that may be of interest to owners of other Cushing's dogs.

The IMS and oncologist both received copies of the blood work we had over the weekend, and both called to discuss our options, with the IMS largely deferring to the oncologist. The oncologist thought we might yet have one sliver of hope: that the numbers from the liver were resulting from localized damage from the well-defined tumor.

By Wednesday we decided we had nothing to lose by gathering a little more information: Aleah was fading fast. We agreed to a second blood count, an ultrasound, and a liter of subcutaneous fluids to counter her dehydration.

The blood count showed the liver failure had worsened, with alkaline phosphatase up to 6760 and AST up to 698. Bilirubin, normally 0.1-0.5 mg/dL, had shot up from 1.4 last Friday to 6.0, making her quite jaundiced. None of this came as a surprise.

The ultrasound of the liver showed it to be filled with nodules and masses of various sizes and densities. The oncologist said that this was most likely cancer. One other possibility that she raised was that there may have been some sort of inflammatory liver disease (don't remember the name of it) that had been suppressed by Aleah's overproduction of cortisol. Controlling the Cushing's may have freed the disease to overcome her liver. In either case, the prognosis was very poor, and rather than hospitalizing Aleah with a good chance of her dying alone and afraid in a strange place, we decided to let her go in comfort.

The ultrasound also showed something that others here can take hope from, however: the mitotane therapy was working. Her ultrasound before therapy showed a right adrenal nearly 3 cm across; this had shrunk to less than 2 cm. The smaller left gland had also shrunk slightly. This reduction occurred without any of the electrolytes getting out of whack, which I take as evidence that the adrenals weren't damaged more than we wanted by the mitotane. Though the dose seemed heavy compared to what's used for most Cushing's treatments, the IMS nailed the dosage. Had it not been for the unexpected liver complications, it appears the Cushing's would have been well controlled, and could have given Aleah a good quality of life.

Aleah's case was extraordinarily complicated, likely involving at least three distinct cancers, and possibly a fourth. Readers shouldn't count Aleah's passing as evidence that dogs with Cushing's will have a poor chance at a good, long life.

Hugs to your pups from us,
Dave & Kit

[littleone1]

Hi Dave and Kit,

I am so sorry for your loss. You did what was best for Aleah. She was loved so much, and you did everything you could possibly do for her.

Cushings is not a death sentence, but there are so many other issues that our furbabies encounter. They are just like us. There comes a time in their lives when there is nothing more that can be done.

Rest in Peace Aleah.

Hugs,

Terri

[Squirt's Mom]

Dear Dave and Kit,

My heart is saddened by Aleah's passing. She had great parents and good docs doing all they could for her and she fought the good fight. The love you shared is obvious in every post. I am so sorry for your loss.

Aleah's name has been added to our In Loving Memory list so she will always be remembered and honored by her family at K9C. In time, I hope you will come back and share some of your memories of your life with her with us.

Please know we are here if either of you need to talk.

Our deepest sympathies,
Leslie, Squirt, Trinket, Brick and our Angels, Ruby and Crystal


Remembering All Who Have Left Us (2011)
http://www.k9cushings.com/forum/showthread.php?t=2865

Tributes:
In Loving Memory
http://www.k9cushings.com/forum/forumdisplay.php?f=8

[Squirt's Mom]

SEPARATE LIFETIMES

We who choose to surround ourselves
with lives even more temporary than our
own, live within a fragile circle;
easily and often breached.
Unable to accept its awful gaps,
we would still live no other way.
We cherish memory as the only
certain immortality, never fully
understanding the neccesary plan....

--- Irving Townsend ---
"The Once Again Prince"

[BestBuddy]

Dave,

Aleah had her special week and then had to go, free from pain and disease There are no words to help but I am thinking of you and your family.

Godspeed Aleah

Jenny

[Harley PoMMom]

Dear Dave and Kit,

I am so, so sorry to hear of the loss of your beloved Aleah. You were the best parents and your deep love for her most definitely showed.

Keeping you all in my thoughts and prayers.

With Heartfelt Sympathy,
Lori

[Dave Ruske]

Thank you all for the heartfelt support, it is deeply appreciated.

Dave & Kit

[makita1996]

Dave and family,
So sorry to read about your loss....... I wish there was something I could say to help 'ease' the sadness.... You took the time to acknowledge my loss and I appreciated that.....Although your messages bring back some sad memories of my own loss (Makita), I laughed when I read about the licking of the dinner plate.... and smiled when I remembered how I would sometimes let Makita lick a plate and how happy she would be..... take care.....

[apollo6]

Dear Dave & Kit
Our inability to completely protect and keep from harm those we love is a painful but inherent part of the human condition.
Let solace be taken, however, in knowing that we gave the best we had to our little friends, and that they knew, without an inkling of doubt, that they were deeply loved.
For, beyond all else, that is the greatest gift we give to them, and in turn, the greatest gift they give to us.
WITH SINCERE SYMPATHY
FOR YOUR LOSS

It took a lot of courage to post about hope for others despite the loss of your Aleah. May Aleah rest in peace.
LOVE
SONJA AND APOLLO

[Spiceysmum]

So sorry to hear about Aleah. Thinking of you both.

Linda

[addy]

Dear Dave and Kit,

There is a bright star now in the Wisconsin sky. I will think of you and always remember Aleah when I gaze at the evening sky. Thank you for sharing your story. Aleah was so blessed to share her life with you. Your devotion to her can only help us all know jusy how amazing she was.

Love,
Addy

[Casey's Mom]

Dear Dave and Kit,

Thank you for thinking of us and posting when your loss was so sudden and sad. You gave Aleah a wonderful life, and the sky now has a brighter star to look down upon you.

Love and many hugs,

[SachiMom]

Dear Dave & Kit,

I was truly hoping that you would have more time with sweet Aleah. I knew that you would only do the best for her, as
you have done her entire life. She was a lucky pup to have such loving and caring people to call her own. Although it was the right decision, it doesn't make it easier or hurt less. My heart hurts for you. I wish I had words to help, but you also know that only time can ease that pain.

Godspeed Aleah. Run with the wind.

Luv & Hugs
Mary Ann

[Wally P's Mom]

I am so sorry for your loss.

My Wally passed one month ago from oddly the same thing.

I found this book offered hope which is something of comfort these days. It is called "Cold Noses at The Pearly Gates" by Gary Kurz.

May you find the peace and comfort you seek.

Marge

[Bichonluver3]

Dear Dave Kit,
My heart breaks with the sad news that our sweet Aleah is no longer with us - for, indeed, she belonged to all of and always will. You were amazing parents and she knew how deeply she was loved. What a wonderful gift you gave her - the opportunity to make a peaceful journey from her own loving home with Mom and Dad with her. You are very special people.
To Aleah; run free, sweet angel, full of youth and health. Bask in the warmth of heavenly sunshine and sleep as gentle breezes whisper to you of the love that surrounds you. You live in the hearts of all of us still battling this disease and you give us strength to continue to fight.We will all miss you, our precious princess. Til we all meet at the Rainbow Bridge someday, godspeed and God bless.
All ou love and heartfelt sympathy,
Carrol & Chloe

[jrepac]

Rest in peace Aleah.

Jeff & Angel Mandy

[Franklin'sMum]

Dave,

I am so very sorry to hear of Aleah's passing. She will always be loved and remembered. Sending you love and prayers,

Jane, Franklin and Angel Bailey xxx

[Dave Ruske]

Thanks so much to all of you for your kind words, support, and prayers. It has meant a great deal to us.

All the best to you and your pups,
Dave & Kit

[Marge: I'm sorry to hear about your Wally, too. And thanks for the "Cold Noses at the Pearly Gates" book recommendation. I just downloaded a copy from Amazon and I'll give it a read; it sounds interesting, and it's certainly a topic Kit and I have discussed over the past few days.]

[k9diabetes]

I am sorry to learn of Aleah's passing... it is hard when you've worked so hard to deal with something like Cushing's disease only to find there is something much more threatening going on. Aleah was blessed to have you in her life.

Natalie