Doubts on surgery for atipycal Cushing

[Keysia]

We luckily have found this forum and we would wish to hear from anybody here with is, or has been, under the following situation.

Rorty, is a cross breed, very similar to an Australian kelpie, of about 8 years old. She had been diagnosed with Leishmania several years ago. She is currently controlled so she is apparently healthy, strong and happy.

However, about one year ago she started drinking more water than usual, urinating very frequently and constantly hungry. An ACTH stimulation test together with other tests, ultrasounds, etc were all negative. Symptoms were consistent with Cushing’s disease but this did not appear to be the case according to the tests.

After one year under such symptoms we decided to repeat the stimulation test which again was negative. Abdominal ultrasound was also performed. A mass in her left adrenal gland was this time observed.

We rapidly contacted Dr. Xavier Roura, a veterinarian of the Veterinarian Teaching Hospital at the College of Veterinary Medicine at the Universitat Autònoma de Barcelona (Spain) who confirmed us an atypical Cushing disease. Medication (Vetoryl and Mitotane) were not helpful. This means that Rotry’s body is not producing cortisone in amounts higher than normal (as in a typical Cushing disease) but it is any other hormone. However, we tried to control her symptoms through Vetoryl. After ten days of treatment, cortisone levels were highly reduced in a way that she was almost in the opposite condition (Addison disease).

Rorty is at this moment an apparently healthy dog, only with typical symptoms of polyuria, polydipsia and polyphagia. Otherwise, she eats well, she is very strong, she is powerful, and no abdominal swelling or hair loss is observed.

At this point, the treatment for symptom control appears not to be possible. Therefore, we were advised for surgery in order to excise the mass. The mass is currently not very large and it is not invading surrounding organs, veins or arteries.

The question is that surgery is risky (mortality rate of about 25%) so we currently have a lot of doubts. In addition, we are not sure how recovery will be after surgery. We don’t know how Lehismania could affect her after (or during) surgery. We don’t know what to do.

We expect that anybody here can provide us with an opinion so that we can take the most correct decision. We will be very grateful if any of you who have been (or is) under this or similar situation in having to take such a difficult decision on their dog can help us. Rotry currently looks very well and we would want to do our best for her, and her quality of life, but we wouldn’t want to lose her on the surgery table.

Thank you for your comments!

[Squirt's Mom]

Hi Keysia and welcome to you and Rorty! :)

Atypical Cushing's is a condition is which the cortisol is normal but one or more of the five intermediate, or sex, hormones are elevated. Those hormones are Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone.

My Squirt is Atypical; her cortisol is within normal range but all five of her intermediates have been, or are, elevated. She has been on melatonin and lignans since '08 which lowered her levels, bringing the estradiol back to normal! :D Melatonin and lignans is the treatment approach recommended by the University of Tennessee in Knoxville (UTK) who leads the research in the arena of Atypical Cushing's. Lysodren is used in conjuction with or alone in treating Atypical as well. Squirt is now on a maintenance dose of Lyso along with the melatonin and lignans because she started exhibiting stronger signs and her cortisol was creeping up, tho still within the norms.

UTK does not recommend using Trilostane (Vetoryl) with Atypical pups as it has been shown to elevate some of the intermediates. However, it has been used with these pups with success among our membership. There is a great deal of controversy concerning Atypical Cushing's so finding a solid treatment recommendation is difficult - everyone has their own ideas, opinions, and experiences....medical professionals as well as parents. The treatment approach I used with Squirt worked for her but it might not for Rorty or any other pup. ;)

The mass on the adrenal....did they tell you what type of tumor it was? Does pheochromocytoma sound familiar? Depending on the type of tumor, it could be causing the signs you are seeing as well as the results of the hormone test. We have several members who have experience with adrenal tumor surgeries and I am sure they will be along to share with you but if you can tell us the type of tumor found, that will help us give you more meaningful feedback.

I am glad you found us and look forward to learning more about both of you as time passes. You and Rorky are no longer alone; we will be with you every step of this journey. Please don't hesitate to ask any questions - if we don't know we will help you research and learn together.

You are off to a good start! :D Keep your chin up!

Hugs,
Leslie and the gang

[addy]

Hi and Welcome,

Leslie has done a wonderful job explaining atypical. I am wondering if we could have a bit more information for our members. It is mentioned that Vetoryl was tried for 10 days. Could we know the dose and also the weight of your dog? The more information you could provide the better our members can try to help and make sense of it all.

You have come to a wonderful forum. Our members are kind, supportive and pretty smart too:)

We are all here for you and will help in any way we can.

Hugs,
Addy

[littleone1]

Corky and I also want to welcome you and Rorty.

I'm glad you found us. We do have a wonderful group. They are very caring and supportive, and have experience in dealing with the different kinds of cushings.

We are looking forward to learning more about Rorty.

Terri

[SasAndYunah]

Hi Keysia,

Bienvenidos from me as well :) Am I correct that you are in Spain?

I saw the name of your veterinarian, dr. Xavier Roura, and I immediately recognised the name as one of the Diplomates in the European College of Veterinary Internal Medicine. My veterinary internal medicine specialist is a diplomat there as well, dr. Paul Mandigers from The Netherlands.

He is one of the leading internal medicine specialists and...on top of that, the authority on canine Leishmania. What is his take on Rorty's situation? I have no idea what the surgical risks are in dogs with Leishmania (other than that anesthesia lowers the resistance and that could cause the Leishmania to flare up...) but dr. Roura should know more about that, I suppose.

I am no Cushings expert but if Rorty has no elevation of her cortisol levels but only one or more of the sex hormones, the treatment usually is treating with Melatonin and lignans, as others have and will explain :)

Wishing you and Rorty all our best,

Saskia and Yunah,
The Netherlands :)

[Keysia]

Thank you very much to all who are reading our post and all who are leaving replies that are very valuable for us. It's very comforting hear from people having great knowledge about this disease.

We effectively are from Barcelona (Spain). Sorry if anything written here is not correct (it is not easy to accurately express our questions in these medical terms).

Squirt's Mom: unfortunately nobody is able of confirming if Rotry has either a pheochromocytoma or an adenoma. They told us that the standard protocol to be followed in this case of atypical Cushing in which medication (Mitotane-Vetoryl) is not useful is surgery; and then analyzing the mass once it has been removed for confirming whether it is a pheochromocytoma or an adenoma. This is another reason for our doubts in what to do. If the mass is a pheochromocytoma symptoms will then get better during a period of time but they could come back again so her life expectancy could be the same as if nothing is done (no surgery). In this respect, does anybody know if there is any test for knowing which other hormone is she producing out of the ordinary and giving her a suitable treatment other than surgery?

Addy: Rotry weights 29.7 kbs (13.5 kg) and Vetoryl dosage was 30mg every 12h for 10 days. Before Vetoryl administration the ACTH stimulation test provided normal cortisol values. After 10 days of treatment levels were quite under normal. In addition, symptoms did not get better so they told us that the risk of reaching an Addison with such a little progress in polyuria, polydipsia and polyphagia was not worth.

As for leishmania, the major risk is that anesthesia and recovery may result in a drop in defenses and a flareup of the leishmania resulting in vital organs to be attacked. According to Dr. Roura's opinion, Leishmania is at present well controlled and all the blood tests performed are ok, and therefore the Leishmania is not the main concern now.

The problem is that we don't know which type of tumor we're talking about, whether it is benign or malignant, or which type of hormone(s) is/are being produced.

We now see surgery as a risky option and with no guarantees of survival, recovery, kind of life, medication to be administered, etc, but we are not sure about anything.

The last testing was performed on March 30th 2011. If any parameters could be relevant, we can put them here.

Thanks again to all of you!

[Buffaloe]

Hello and welcome,

My dog, Shiloh, was diagnosed with a very large adrenal tumor in her left gland in October 2006 at the age of 12. She had all the cushing's symptoms and was not doing well. She had a very successful adrenalectomy and lived well into her 15th year with an excellent quality of life. It was a difficult thing to go through but for us, surgery (adrenalectomy) was the only real option.

In the United States, a dog with an adrenal tumor would not be called atypical. It would be called adrenal cushing's or a dog with a primary adrenal tumor. But, virtually every dog with an adrenal tumor has an elevation in some of the intermediate (sex) hormones. About half of all adrenal tumor dogs display elevated cortisol. There are at least 7 or 8 different kinds of canine adrenal tumors. The most common is a cortical adrenal tumor, which is what Shiloh had. We did not know the type prior to her adrenalectomy, which is very common.

Because Rorty's symptoms are not bad and the tumor is relatively small (minimal involvement with vena cava, etc.) I really don't think you need to be in a hurry to make a decision. An adrenalectomy should only be performed by a very experienced and highly skilled surgeon in a state of the art facility with 24 hour veterinary care. If these conditions are met, the long term success rate should be at least 85% in Rorty's case. Removing tumors in the left gland are significantly easier than in the right. But, make no mistake, it is a very serious surgery with risks. We had a tremendous board certified surgeon do Shi's adrenalectomy and he was assisted by another wonderful bcs. A consultation with the right surgeon would probably be very insightful for you.

Below is a link to the University of Tennessee. They offer a full adrenal panel with an ACTH test which gives the readings of all of the intermediate hormones. Dr. Oliver has various treatment options. Click on diagnostic services, then endocrinology.

http://www.vet.utk.edu

Surgery really is the treatment of choice for a dog with a primary adrenal tumor. But, you have to realize, there is a chance Rorty wouldn't make it. But, in my opinion, with the right surgeon, the chance of him not making it is no where near 25%. Again, you have some time; adrenal tumors don't grow that quickly. All the best to you and Rorty.

Ken

[frijole]

Saludos!

My dog Annie has a pheochromocytoma and you are right, her symptoms come and go. She was treated at a university here in the U.S. and they said that the determining factor that labelled it a pheochromocytoma tumor was that she would sometimes have high blood pressure.

My dog has "cushings like" symptoms that come and go and although never tested, I am sure her sex hormones are elevated as well. This has to do with the function of the tumor. So I have been giving her melatonin which calms her down but also has helped with her hair loss.

She was diagnosed one year ago and I have elected not to do surgery. She has good days and not so good days. I am glad that you found us and wish you the best. Kim

[Keysia]

As you know, we (still) have may doubts about surgery even after having several visits with Dr. Xavier Roura, a consultation with surgeon (Dr. Félix García Arnás) as well as a final consultation with both in order to contrast opinions. While the surgeon is more optimistic for Rorty, Dr. X. Roura is somewhat more pessimistic. We asked him about how many of such operations was he performing per year. He told us that about six. They do not seem a lot, but he is the surgeon performing adrenalectomies there.

Finally, after reading this forum together with the veterinary visits and after much thought we have finally decided to operate her. We are very afraid since the operation is risky and we could lose her. However, we think that this is the best for her. Operation will be next week.

Let's hope everything turns out all right so that we can write here back after operation with good news.

Thank you for your helpful comments!.

[addy]

We will all pray for a good outcome and our thoughts are with you. I can only imagine how stressful this is for you and how worried you are.

Hugs,
Addy

[littleone1]

I'm sending positive thoughts and prayers that the surgery is very successful.

[Squirt's Mom]

Hi Joanne,

It is so scary waiting for a surgery that you know is risky. My Squirt had to have a tumor removed from her spleen and the days between setting up the operation and the actual day of surgery were exhausting. I was scared the tumor would rupture before the surgery, afraid she wouldn't survive the surgery, my emotions were all over the place but fear reigned supreme. Several of us have been where you are and understand what you are going through even tho the reasons and surgeries may be different.

Don't sit there and work yourself up into a tizzy; we are here and more than happy to talk with you. We may not have answers to all things, but we do have compassion and empathy. Please let us know when the operation is scheduled for so we can sit and worry with you. :)

Hugs,
Leslie and the gang

[Buffaloe]

Hi Keysia,

I am glad your surgeon feels good about Rorty's adrenalectomy. I completely believe they are the ones who know the most about these things. If he performs six adrenalectomies a year, that's quite a few. That is about the same as Shiloh's surgeon.

I know all adrenalectomies involve a good amount of risk but Rorty has ALOT in his favor. At eight years old, he's way younger than most dogs who go through this surgery. The tumor is pretty small and is in his left gland. And there's no involvement with the caudal vena cava. My surgeon told me that all he cares about with adrenalectomies is the size of the tumor and its involvement with area blood vessels.

You and Rorty will be in my constant thoughts and prayers. I remember clearly how difficult it was to go through Shiloh's adrenalectomy almost 5 years ago. Rorty is a strong, young boy and he has a small tumor. Try to hang tough.

Ken

[Keysia]

Thank you very much for your words and your support.

The operation will be tomorrow. We hope to write here again… with good news.

[Squirt's Mom]

Hi Keysia,

Please know we are here at any time if you wish to talk. It can get quite nerve-wracking waiting for surgeries to be over so know you are not alone - we are by your side, anxiously waiting with you.

Sending you positive thoughts, healing white light and many prayers for tomorrow.

Hugs,
Leslie and the gang

[Keysia]

Hi guys!,

After much suffering, operation was well. It was quite complicated but nothing out of the ordinary. Fortunately no unexpected things occurred.

The surgeon detailed us what he did: a 1.4cm mass was entirely removed although being closely attached to a vein (vena cava or renal vein, we are not sure which). The boundary of the mass was first dissected from the surrounding tissues and the attaching portion thereof was then removed by fitting a surgical clamp on the wall of the vein. In short, Rotry responded well to the anaesthesia and vital sings were normal. We were however worried about the postoperative period since it is critical within the following 24-48h. Apart form a specific temporary rise in her blood pressure which was well controlled, she responded again well to medication. She is now well, eats and even walks. She is still in the ICU but now most of the medication is now administered orally.

Discharge is expected this afternoon, after which we will be informed about treatment and the like. In the next few days we will know the results of the biopsy of the mass removed.
We are now happy at the moment knowing that she is ok.

We were lucky in finding this forum with such nice people.

Rotry wishes to thank you everybody here for your helpful support!

[Harley PoMMom]

So happy to hear that Rotry's surgery went well and that she is doing so good...eating and walking, very positive signs!!!

Sending tons of healing energy your way for Rotry's speedy recovery with huge and loving hugs, Lori

[Squirt's Mom]

Mornin',

I am so happy to hear that Rorty's surgery is over and went so well! It sounds as if his recovery has been easy and that's good, too. Once he gets home, he will start to improve even more!

Keep in touch and let us know how things are going.

Hugs,
Leslie and the gang

[Buffaloe]

Hi Keysia,

What wonderful news on Rorty!! I am so happy the surgery and post-op went so well. I am hoping and praying that you will have a whole bunch of happy years together with her.

My only suggestion is to keep Rorty real, real quiet for the next 7-10 days. There is so much healing going on. She's probably going to be feeling pretty darn good in a few days but you shouldn't let her run or jump...at all.

Thank you so much for letting us know about Rorty.

Ken

[addy]

Oh, such good news!!!!

I am so glad everything went well.

Lots of love and rest for you both :)

Hugs,
Addy

[littleone1]

I'm so glad that the surgery went well. I know you're very relieved that Rorty did so good, and that in no time, he will be his normal self.

[terreh1]

Hi there,
I was just reading all the posts regarding Rorty's surgery. I am very curious how he is doing now that a couple of months have passed.
I have scheduled an adrenalectomy for my dog, Max next week and I am having major anxiety over it! I would love to hear some good news regarding your dog.

Thanks!
Terre and Max