Calcinosis cutis and surgery? - URGENT, HELP!

[dcbosty2014]

My sweetheart 6 year old Boston terrier, Bella, was diagnosed with Cushings on Friday after a Dex suppression test. Cushings was first suspected after elevated liver enzymes were discovered during a preop blood panel. I originally took Bella in for a small lump in the skin on the back of her neck. Bella has had 2 mast cell tumors removed in the past, so at first this is what we suspected. So we scheduled surgery to remove the lump.

A few days later we confirmed Cushings. I read that one of the possible side effects of this hormonal imbalance is Calcinosis cutis. The more I read, the more I considered this might be the cause of the lump. Aspiration showed no mast cells but afterwards the bump became much larger and did not shrink back down as her mast cell tumors have in the past. Also this lump is rock hard and ulcerated, much different from her previous MCTs. I am afraid that if this is calcinosis cutis, then the trauma of surgery could make it worse. Then again, it could be a tumor which could be worse than CC. I voiced my concerns to my vet who told me (through the receptionist) that it was a very rare condition so bella probably didn't have it; even if it was CC not to worry, surgery shouldn't make it worse.

I am concerned that the vet didn't think of this condition in the first place and has no experience with this condition to inform her opinion. I feel a bit dismissed. I keep thinking "first, do no harm" and hate the thought that surgery could make things worse.

Does anyone have a similar experience? Are there options other than a huge removal, maybe like a punch biopsy or something to first determine what it is? Surgery is scheduled for TOMORROW and I am not feeling confident in this decision. Thank you so much in advance for your insight and support!

[Harley PoMMom]

A biopsy or skin scraping can be done to diagnose calcinosus cutis. We have several members here whose furbaby's are dealing with calcinosis cutis.

Calcinosis cutis is usually secondary to another issue, Canine Cushing's is one of those diseases that Calcinosis cutis can be secondary to. When a dog has Cushing's with concurrent Calcinosis cutis getting the elevated cortisol within the therapeutic ranges is needed.

I am a bit concerned that the vet did a LDDS test while Bella has something going on with her skin, the LDDS test can create false positive results when other non-adrenal illnesses are present.

Hopefully other members that are more knowledgeable about calcinosis cutis will chime in soon.

Welcome to our family and I am sorry for the circumstances that brought you to us, remember we are here to help in any way we can so do not hesitate to ask all the questions you want.

Hugs, Lori

[lulusmom]

Hi and welcome to you and Bella.

I have manually validated your membership so that members can see your post. You can disregard the email we sent to you asking you to validate.

It seems that we have an increase in members who are dealing with calcinosis cutis so you will have lots of folks sharing their experience and probably directing you to pictures of their pups. It does seem as though the short snouted breeds seem to be over represented. It can be very difficult to get under control and it's tough to watch the discomfort your pup is experiencing. Most experienced vets will do take a portion of the mass for biopsy. My dogs did not have calcinosis cutis but I was always quizzing their internal medicine specialist. He told me that sometimes they take the entire mass if it's a small area so perhaps having your vet take the entire growth isn't such a bad thing. I'm sure that others with more experience will be chiming in.

Glynda

[dcbosty2014]

Thank you all so much for your input; please keep it coming.
I would attach a pic but 1. I don't know how to and 2. I'm not sure how informative it would be. The lump is approximately 2"x0.75" so not super small. Because Bella has previously had mast cell tumors, the vet is going to have to treat the lump like one and take wide margins (5cm around the lump) - she may take a little less bc we don't have confirmation of a mast cell tumor.

I didn't bother to ask about false positive rates and causes, and definitely should have so thank you for bringing that up. Bella has had a host of other symptoms (recurrent skin and bladder infections, hair loss, excessive drinking and urination)...unfortunately up until this point I had attributed this to stress due to the arrival of our first furless baby (sounds so much better than skin baby lol).

When you guys say biopsy do you mean something that is performed without sedation?

I am so worried about Bella. She is my first dog and definitely my heart dog and cuddle bug. All of the information you guys give me helps me to feel more informed and confident in our tx plan, so many many thanks.

[Dawn Anderson]

Welcome to.the forum you have come to the right place for.advice, be prepared for lots of ? about your pups lab work. I'll throw my 2 cents in since my girl has CC and also had a small tumor on her belly ( about the side of a qrter)removed at the same time the skin punches were done for confirmation of calcinosis cutis(CC), it took almost 5 weeks for the areas to heal enough to have the stitches removed , which in a normal dog it would have only been 2 weeks. Since the LDDS test showed a possibility of some sort of glandular issue, by chance did the vet give you the numbers from the test and if so could you please post them for us. I would only do the skin punches to diag the skin condition since it is not acting like MCT that you are use to and a ACTH test. There are other conditions out there that can cause a skin condition and Cushings can be a little tricky to diag if other issues are going on with in the endo. system.

Knowing what I know now about this , and if Bella were mine I would only do the skin punch and a ACTH test if all other lab work for thyroid and diabitis are good.

Wishing you and Bella all the best, many of us here are in different stages of Cushing's and are here to help in anyway we can.

Dawn and Buttercup

[dcbosty2014]

Sure I can give you some numbers...
Low dose Dex suppression test:
Baseline: 5.2
4 hour: 4.5
8 hour: 4.2
Alkaline phosphotase: 1242
ALT: 195

These are the only results the vet shared with me....she didn't say anything about thyroid testing, although I have no idea what is included in a pre-op panel. She told me the Dex sup results were more indicative of an adrenal tumor; we will try to do an abdominal ultrasound 1 week after surgery, although I'm not sure she will be healed enough by then to lay on her back. I'm reeeeally hoping it's not an adrenal tumor.

[Renee]

Hello and welcome.

My pug Tobey has cushings and calcinosis cutis. You can check out our thread to read about her, and more importantly, go check out her album. I will try and link to it in another reply. It has some good pictures of the beginning stages and progression through a few weeks. I have been a bit lazy and not updated it in a few weeks.

We confirmed CC with punch biopsies on five different lesions. The skin scrape we did before the biopsies did not reveal anything. Tobey was sedated, but not completely knocked out. I think you can safely do the biopsy and then if it comes back and an MCT, then go in and remove. I do not suggest removing an entire CC lesion. The skin is very, very different than normal skin. When Tobey had her biopsies, the skin was so damaged and thin that the stitches literally just ripped right through. She had open areas for quite a while. The skin of CC is almost disintegrating during certain cycles and I just can not imagine removing an entire lesion.

I suggest doing the ACTH too, although cushings does sound likely for your girl.

[Renee]

I hope this works, here is the link to Tobey's album with pictures of her CC.

http://www.k9cushings.com/forum/album.php?albumid=805

[lulusmom]

Dogs with adrenal tumors usually don't suppress at all but Bella did suppress, so while there is no way to tell without an abdominal ultrasound or endogenous acth test, the law of averages says the odds are much greater that Bella has pituitary dependent cushing's.

Glynda

[Dawn Anderson]

I have also created an album, just go to my home page ( not sure how to create a link yet like Renee did) its titled battleing cushings. I also agree with Renee that you should not have the lesion removed skin effected by CC is very fragile and doesn't heal well.
I highly recommend Trizchlor spray conditioner it is a antimicrobial spray to help prevent secondary skin infections and Mupirocin ointment for any open or weeping areas, they were both given to me by Buttercups vet at UC Davis VMTH and have been working well. Also keep in mind the dryer you can keep the areas the better to much moisture can breed bacteria and yeast.

Thank you for posting Bellas results. Be sure to ? Her vet regarding how many cases of Cushings she has treated, its very important that the vet has experience and if not, that they are open to working with an IMS on behalf of Bellas well being.

Dawn & Buttercup

[dcbosty2014]

Thank you everyone for all of your information. I went to the vet this morning and voiced all of my questions and doubts. I asked why she had not recomended a punch biopsy and she told me it was because they don't heal as well and almost all of the time they have to go back and remove the mass anyway. She pointed out how much smaller the lump had become since we started antibiotics and was worried that if we waited to do surgery that the lump may become larger and she would have to take even more skin. She also said calcinosis cutis is normally the result of years of undiagnosed cushings, and that Bella had most likely not had it for long - her liver enzymes were just slightly elevated 6 months ago. I went in really thinking that we wouldn't do surgery but when it came down to it I had to chose the lesser of two evils: either do the surgery and risk aggravating the potential CC, or wait and allow a possible tumor to spread. I feel like a pushover for not following my instinct. On the way home I found another hard bump about two inches below the incision between her shoulder blades. This made me think even more that it was CC and made me question my decision all over again. I trust this vet but she just seemed so convinced it wasn't CC just because it is a rare condition, which means that it is unlikely that Bella has it; not impossible. I feel like such a bad dog mommy but I felt like either way I was damned. I will update with biopsy results once I get then. Thanks again for all of your support.

[molly muffin]

Hello and welcome to the forum.
Oh sweetie, you are not a bad doggie mommy at all.
All we can do, is take all the information we have and then make what we think is the best decision based upon that information. That is what you did.
It may turn out that it was the best way to go and that this was a tumor. It may turn out that it is cc, it maybe be something else, just a lipoma even, but you can't go back and second guess yourself. You made your decision upon what you knew and thought at that time. Now you are looking forward to getting that spot healed, waiting on the report to come back and keeping an eye out on the other area you noticed.
Always look forward and only look backwards in regards to information gained to take forward with you.
Welcome to the forum,
hugs
Sharlene and Molly Muffin

[Renee]

Don't feel bad! It is hard to know the right decision and stick with it 100%. We have ALL felt moments of indecision, myself included. To top it off, when we get an overload of information, it can be hard to muddle through it all.

If you look at my thread, you'll see that my vet dismissed the possibility of CC as well, due to its rarity. In fact, we were all convinced it was cancer. And, to top it off, my pug does not have / never has had, elevated liver function, which is a big tip off for cushings.

All this means is that we all come to the diagnosis in one way or another, and just try to do our best along the way. I truly pray that your girl does not have CC, as I personally feel it is one of the most terrible cushings side effects ever.

[Dawn Anderson]

OK throwing my 2 cents in,
pasted from your post

"calcinosis cutis is normally the result of years of undiagnosed cushings"

That in my opinion is a bunch of BS, not all dogs react the same and my girl had completely normal lab work 02-13-2013 when she had her yearly lab work done and the also did inhanced blood work because she was going to get her teeth cleaned on 02-15-2013and would have to be put under for the cleaning.

Had to take her in in late Aug. 2013 due to not moving good, blood work showed slightly elevated liver values, compared to to Feb. (she has back issues), Sept up again, Oct Up again, on the 27th of oct the first lesion showed up, punch done on 11-2, confirmed CC and reading off the rictor scale.

I really hate when Drs and Vets lump all cases into 1, they are all individual and they really can not compare 1 case to another. " NORMAL", HUH, there is nothing normal when it comes to Cushings, nothing at all!!!!!!

Again, I have become very sensitive to what we Cush parents go threw and I have read so many reports of very poor Vet care, and the damage they casuse both the pup & the parent, it just makes me see RED.

So keep asking ???, never let up, you are your babies voice!!!!! I would be very leery of a Vet pushiing for mass removal, knowing what I know about CC. To many see our babies as cash cows. I would rather deal with a small punch wound with 2 stitches then a much larger area that has multiple stitches....


Again it just my 2 cents


Dawn & Buttercup

[Dawn Anderson]

Do not beat your self up, at 1 point ALL of us here were in your shoes, newbies to the whole Cushings "thing", you are a very loving mommy for feeling like you do, your bond is strong with Bella and no matter what you did & do, it is all out of LOVE. Keep educating your self and come to us with ANYTHING, we are all here for you.

Hugs to mommy and pup

Dawn & Buttercup

[Dawn Anderson]

Me again,

What did the Vet give you for the after care of the surgical site????

Dawn & Butters

[dcbosty2014]

She didn't give me anything topical. Bella will be on antibiotics and rimadyl for a while and some type of narcotic for the first two days. She has dissolving stitches on the inside and a few traditional stitches on the outside. I will be scheduling an abdominal ultrasound next week once she is healed a bit. So far she is in waaay less pain than the last two surgeries which is great. I got her canned food to make med meatballs, probiotics and pumpkin to soothe her easily upset tummy, and a hot pink care bear for cuddles.

Re: the possibility of something other than cushings - my vet said her blood sugar was normal so no diabetes; she said thyroid issues wouldn't cause that cortisol pattern during the Dex sup test. Bella hasn't really had much of a disposition change which I would expect if she were having thyroid issues - then again I am no canine endocrinologist. I will look more into this.

Do most of you guys see an endocrinologist? Or do you have your general practice vet manage the cushings? Or a combo of the two?

[Dawn Anderson]

Glad to read that Bella is as comfortable as possible. Butters & I are working with a IMS at Davis and with her Vet here at home. A real tag team.
I am sure your watching her like a hawk and she will love the additional attention. Wishing her a speedy recovery from the surgery.

Hang in there mom, your doing a GREAT job!

Dawn and Butters

[dcbosty2014]

Biopsy was positive for calcinosis cutis. I should have just listened to my gut. Bella now has a spot between her shoulder blades two small spots on her thigh, and there is a hard spot developing just above her incision. She got an abdominal ultrasound which showed both adrenals were enlarged so she has pituitary cushings. The vet put her on vetoryl and after a consultation with a dermatologist decided to give me DMSO for the lesions. I hopefully will take some time today to read a but more about CC treatment. What have you all had success with?

[lulusmom]

Bumping up so that members with cc experience will see and respond.

[Renee]

I tried the DMSO, and saw no results. Not to mention, the stuff is disgusting. The smell is just awful. I stopped after a few weeks. I just could not keep going with it.

What really helped was 1. getting on abx to kill infection (which she did have, after the biopsy), and 2. getting the cortisol low enough. It's not the answer anyone likes to hear, because getting the cortisol low enough can take a while.. but, it seems to be the only true answer. Let them run their course and get the cortisol down into therapeutic ranges.

[Dawn Anderson]

Dang , Bella has CC, ok , are you going to have a MRI or C-scan performed so that you know just what the condition of the pituitary is? Is it a micro or macro tumor, that is the ? that you need to get an answer for, is it a slow grower or fast, that is the next ? you need an answer for. There is not much room in a canines skull for tumors. Butters tumor was a fast grower macro that was reeking havoc on her, she was anything but atypical.

Once you get the answers to those questions you can then really wrap your hands around the situation and will be able to make an educated decision on what is best for Bella.

Renee is correct, keep infections at bay and hormone under control is really the only thing you can do for the skin while it goes through its cycles.

Hang in there
Dawn and Butters

[Dawn Anderson]

Me again, by chance do you have a Vet. Medical Teaching Hospital like UC Davis that you can take Bella to? Or any other University that has a VMT dept.? If Bella was my girl that's where I would take her next. Is Bella vet an IMS or a GP?

Dawn and Butters

[dcbosty2014]

Thank you!! The vet gave us DMSO but didn't say anything else about any other topical meds. She also started bella on 30mg vetoryl for a 13 lb dog. I thought this sounded a bit high. I guess she is starting her on a higher dose since she has CC....

[dcbosty2014]

In the mid Atlantic here so no teaching hospitals that I know of...we would have to go to a VCA referral hospital and see the internist there.

What would getting imaging of the pituitary gain (aside from additional info/more accurate prognosis)? I would only do additional imagining if it helped the tx plan.

[Arizona Boston]

Hi,
My Boston Lucy has the CC. It's not gone, but in the clearing stages. She has gone to three different vets and none of them suggest a biopsy or skin scrapping. I think once the ACTH came back positive, the CC was a foregone conclusion and the goal was just to get the cortisol level down. My thoughts are like Renee's….give a good skin antibiotic for a while and let the ACTH levels get low enough for the healing to begin. But I did baths also…and topicals also… Lucy even wore T shirts to cover sometimes. It's like having bad acne…you just want to keep trying until something makes it a little better.
( Lucy had a history of Mast Cell tumors in the distant past also. )
Good Luck and keep on trying.
Shelly and Lucy

[dcbosty2014]

Awww poor Lucy. With all of these surgeries, sometimes I feel like I have a frankendog.

[StarDeb55]

Here's a late welcome from me, too. I was reading through your thread to get myself acquainted with Lucy's story. I wish I could offer words of wisdom from personal experience with CC or the use of trilostane, but I have neither. So what I could do is a little research & see if I could locate a vet school with a teaching facility that might be doable for you & Lucy. I did find this one, but since I don't your exact location in Maryland, it may not be feasible.

https://www.vetmed.vt.edu/vth/

Debbie

[Dawn Anderson]

Butters tumor grew to be 2.5 cm + and if I had not done the imaging as soon as i did she would have had a very slow pain full death due to all the pressure and swelling that the tumor was doing to her brain. If i would have only done medication to treat the Cushing's she would be dead now and I would have either died from a heart attack from the guilt of not going the extra mile or committed suicide for I would not have been able to live with myself having known that something as simply as a cat. scan or MRI was the key to being able to get the right treatment and save her life.

You are more then welcome to read through my thread there is lots of info. about her diag. and treatments for her PDH.

Dawn and Butters

[Dawn Anderson]

Debbie, that was so helpful, hopefully she's able to get Bella to a VTMH.

Thanks
Dawn and Butters

[dcbosty2014]

What treatment did you do for the pituitary tumor?

[dcbosty2014]

Thank you for the link Debbie. Yea Blacksburg is 3 hours away so I'm not sure that is an option. I mean we could probably go there once or twice but it's far to be a routine thing.

[Dawn Anderson]

Radiation therapy was done to shrink tumor and it has worked well!! Butters Vet. is working with the Vets at Davis as a team so that I don't have to make the long haul up there for her tests now that she had the treatment.

Dawn and Butters

[Harley PoMMom]

My vet has referred me to Chesapeake Veterinary Referral Center located in Towson MD. The IMS that my boys saw was Dr Petrus. Here's a link that has info on Dr Petrus plus other doctors: http://www.avim.us/pages.aspx?content=35

When my boy, Bear, had to have his leg amputated because of cancer Dr Anders was the surgeon, his bio can be found here: http://cvssvets.com/surgeons.php

Chesapeake Veterinary Referral Center link: http://www.cvrc.com/

[dcbosty2014]

Thank you for the information Pom Mom. Towson is just over an hour away so not too bad. The referral center where I took bella has an internist but it doesn't say anything about her specialty aside from that. I may call today and see if I can get a little more information.
How did you feel about Dr. Petrus' care of your pup? Did you feel like he explained things thoroughly and included you as a part of the care and decision making team? I have a medical background so I need someone who is going to work with me and answer my questions.

[molly muffin]

At 30mg for a 13lb dog, you'll want to keep a very close eye on any reaction.
Just to recap some items for vetroyl use:
If once a day dosing, give in the morning, since ACTH test need to be done 4-6 hours later.
Give with food.
At the first sign of any wobbly, diarrhea, not eating, lethargic not being able or wanting to get up, or anything else off, stop the dosage immediately, schedule an ACTH test.
You should be doing a follow up ACTH test in 12 - 14 days any how.
We always worry when it's a higher dosage than 1mg/1lb to start with. You never know how sensitive any given animal is to any medication.

Hopefully you can kick this cc right out the door, but it is one of the last symptoms usually to clear up and takes awhile, looks worse before it gets better.

Sharlene and Molly muffin

[Harley PoMMom]

Yes I did like Dr Petrus, and he did listen to what I had to say. I can be very vocal when it comes to my furbabies :eek::D which he understood.

[Renee]

Sharlene is right, 30mg to start out on a 13lb dog is too high. Tobey is 20 pounds, and she started right at 20mg and had just gone up to 30mg in the past 6 weeks.

Just because your pup has CC does not mean you have to jump right in with aggressive treatment! I fear that your baby could crash by taking such a large dose.

I would have started at 10mg once daily.

[doxiesrock912]

Best to start low and increase as tests indicate. Daisy weighs 11.6lbs and they started her on 20mg. We had to decrease to half of that.

[Dawn Anderson]

Yes low and slow is best. Buttercup weigh 90#s and is getting 10 mg in the am and 10 At night.she's only been on it for 13 days and goes in on sat for her first acth retest