Adrenalectomy, or let nature take its course?

[abby]

Greetings, and thank you all in advance for any guidance. I've been obsessively reading this forum and hope that any of you may be willing to share your opinion about my sweet Cleo as my husband and I make a very difficult decision about her care.

Cleo is a 12+ y/o 38 lb Basenji/Whippet mix. During an ultrasound for pancreatitis last September, our veterinarian happened to stumble upon adrenal abnormalities. Several specialists and many months later, we've discovered the following:

*Cleo's right adrenal gland appears to contain a mass. As of 2/14, is 1.2 cm large. Her initial ultrasound in 9/13 showed it to be 1.1 cm, and a follow up in 11/13 showed a slight growth to 1.2 cm. Doppler indicates that surrounding blood vessels are intact and that the mass is well-contained.

*Cleo's left adrenal is slightly larger than usual, but is properly shaped.

*Cleo received a low-dose dexamethasone test, the results of which were slightly abnormal. Her high-dose test was also slightly irregular, but not largely so. A specialist at UC Davis believes that these tests, together with her U/S findings, seem to indicate both a small tumor near her pituitary as well as her adrenal gland. Based on labs, she is Cushing's +.

*Cleo exhibits no clinical symptoms of Cushing's whatsoever. Her food and water intake are extraordinarily normal...we free-feed her, and she regulates herself so well that her weight does not vary my more than 1/5th of a pound over a period of years. Her activity level is excellent and she is often mistaken for a much younger dog. Her skin and coat are great.


Though her adrenal tumor seems small to me and has grown just .1 cm from 9/13 to 2/14, the Internal Medicine specialist at UC Davis is recommending an adrenalectomy on the right side. His rationale is that it will eventually shorten her life, as she appears to be in excellent health for her age otherwise (liver, kidneys, etc are stellar), and surgery will only become riskier as she ages and the tumor grows. I should also add that this specialist was referred to us from three excellent veterinarians, and I do not believe that I can find a better-respected IM veterinarian in Southern California.

If the tumor was larger, growing faster, clearly malignant, or causing her any physical symptoms, we would have no issue with following his advice immediately. However, as it seems to be relatively small, is growing relatively slowly, and this surgery is incredibly risky, we are terrified of sending our outwardly-healthy dog into a surgery that may end her life.

It may be worth noting that she is very difficult to manage in a hospital environment, and the specialist, as great as he is, seems to think that we are overprotective. However, when Cleo was recovering from pancreatitis, she received the maximum amount of sedation that the vet felt her body could handle and she still chewed through three e-collars and ripped out two lines *while being monitored in a 24 facility*. This is when she was so terribly ill that her blood was quite literally, visibly thick. After a miserable night, the emergency hospital contacted my husband and I and asked that we stay with her in the hospital (which we gladly did)...they set us up in a euthanasia room with our girl for more than 36 hours so she could receive life-saving plasma and fluids. We sat, ate and slept with her, and it was the only way for her to be able to be treated in any way. This unique accommodation -- the first of its kind for the emergency vet -- would not be able to be made at UC Davis. Thus, we have concerns about the post-op period in the hospital, which, if all goes well, will last at least 48 hours.

We are absolutely sick about this decision. We would give anything to keep our girl safe and happy. We feel like we are being advised into sending our seemingly healthy, definitely beautiful, absolutely beloved dog into the line of fire. Can anyone help? What am I missing...what questions should I ask...what would you do, if this were your baby?

Again, thank you all so much for your advice.

Abby

[Harley PoMMom]

Hi Abby,

Welcome to you and Cleo! I am sorry for the reasons that brought you here but so glad you found us.

One of our dear members, Trish, has a dog, Flynn, that had a right adrenalectomy. Trish was also very generous in allowing us to repost her list of questions for an owner contemplating an adrenalectomy for their dog, here is that list:
Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:
1. What type of tumour do you suspect, ?functional, ?non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushings medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances

Part II - Surgery has been recommended as treatment for your dogs adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:
1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anaesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anaesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable.

We have a few members whose dogs have had adrenalectomies, and I am sure they will be along shortly to welcome you and share their advice.

In the meantime, if you could get your hands on all copies of the tests that were done on Cleo and post only those abnormalities that are listed that would be great.

Please do not hesitate to ask any questions you have and remember we are here to help in any way we can.

Hugs, Lori

[molly muffin]

Hello and welcome from me too.

I can't think of anything better than Trish's list for someone who has to make the decision about surgery.
University of Davis is a good place, when it comes to cushings, but every operation comes with risks, that you have to be prepared for and it sounds like you have some added hurdles with the post op situation. Are they fully aware of how bad it was last time?

Feel free to ask any questions and some of our other members dealing with tumors will be around too. They all pop in and out at different times of day/week though. :)

Hang in there. This is a really tough decision to make, we understand that.

Sharlene and Molly Muffin

[goldengirl88]

I just wanted to welcome you and tell you my Tipper has a small adrenal tumor that has had no growth so far. I know how you are thinking and feeling. I am so sorry this happened to your baby, it is definitely a difficult decision to make. I hope all goes well with whatever you decide. Blessings
Patti

[abby]

Thank you all for the kind words of welcome and guidance during this difficult decision. Your support means so much!

Lori, the questions that Trish shared are excellent. I have answers to many of them, but not all; we will be meeting with a surgeon on 2/24 who will share more. I will pull Cleo's labs and share them later tonight or tomorrow as well.

Sharlene, though we explained in earnest regarding Cleo's last hospital experience and encouraged them to speak with the veterinarian who oversaw her care, they were confident that they could handle her. To me, it seemed that they were a bit over-confident...they are an excellent facility, but her behavior is extraordinarily difficult to manage. I am somewhat concerned that we are considered over-anxious parents, rather than rightfully anxious parents, if that makes sense.

Patti, do you mind sharing a little more info about Tipper? I cannot seem to find specific examples of slow-growing adrenal tumors, and I'm very interested in those in case Cleo might be similar. If it's not too much, and if you have the info, do you mind sharing Tipper's tumor size when it was first discovered, the date of the discovery, and the size/date of its most recent review? Also, do you know what type or tumor, and has Tipper been advised to undergo treatment, whether surgical or other? Goodness, I apologize for the barrage of questions...thank you in advance for any additional info!

Thank you again to all! Cleo (even though she is loudly snoring as I write this) and I appreciate it very much!

Abby

[goldengirl88]

I don't have the time to go into Tipper's tests, but I will get into them tomorrow and get you the answers to your questions. Hang in there I know how this feels. Blessings
Patti

[Buffaloe]

Hi Abby,

I don't check in here much anymore but did this afternoon, saw your thread and wanted to reply. My Shiloh had a 5 cm. adrenal tumor in her left gland, was doing very poorly and had a successful adrenalectomy at the age of 12. For us there was no decision and we had a fantastic team of surgeons. Your situation is very different.

A 1.2 cm. tumor is small and she is asymptomatic. There are at least 7-8 different kinds of canine adrenal tumors; some grow quickly and some grow slowly. I am a believer in surgery but if Cleo was my dog I would not even consider it at this time. Our surgeon is a UC Davis guy, highly respected. I got to know him well and I would be surprised if he would recommended an adrenalectomy for a dog in Cleo's situation. You could make an appointment for a consultation with a top BC surgeon and see what s/he thinks. If it were me, I'd just get an ultrasound every 3-4 months and monitor the tumor....and enjoy Cleo 100% throughout every single day and not worry. Good luck.

Ken

[goldengirl88]

Abby:
I am not sure when exactly Tipper's adrenal tumor started growing as my vet was using his ultra sound and it was not picked up I believe. It was thought she just had PDH and upon an US at his office they saw something large and thought it was a mass. It scared me and I made an appointment with an IMS to have Tipper done on the hospital machine that is high definition. There was no mass that the other vet thought was one but then the adrenal tumor was discovered. It is on her left adrenal, and has not invaded anything like the vena cava. It is 1.11 cm x 2.94 it encompasses the left adrenal. The IMS immediately wanted it out and wanted me to schedule with the surgeon. I though about the pros and cons and the lack of this certain surgery performed by their Dr. I decided to wait. Two months later 8-22-13 I took her back and the US showed no change in growth. On 10-15-13 no change in growth . The IMS then told me she would not have it removed unless they start to see changes, so this changed her mind. On 1-15-14 no change in growth. So in June it will be a year with no growth God willing. Don't get me wrong I am not talking you out of surgery and this is just what happened in Tipper's case. Tipper has other factors too that I feel would complicate surgery. Sure I would like to have it gone and no worries, but I am not willing to risk my dogs life ending when she may go on much longer like this and have no symptoms. So yes Tipper is unfortunate to have both types of this disease. It is not common form what I have been told. The truth is with all this going on I think she has done fairly well. I keep on top of everything and that helps. I am not kidding you when I tell you you will have to keep getting the tumor checked regularly and it can make you a nervous wreck waiting and wondering each time , so that is the down fall of this way. It has been said on here too that adrenal tumors are harder to manage the cortisol with. Some on here have had great success with the surgery, and some not so god of an outcome. I will say there is nothing to guarantee that once removed the tumor will not come back. There is nothing to say that Tipper's won't start growing either. This is a very difficult decision not matter how you look at it. I wish you and your baby much luck with this and hope this helped you in some way. Blessings
Patti

[beaglemom3]

Hi Abby,

Reading your post is almost the same situation I am in. My dog Snuggles has a right adrenal gland tumor that grow from 2.55cm to 3.60 cm between November and end of January. Our local vet and sonographer feels it is a pheo tumor. Snuggles is 14 years and 6 months, at this point we decided not to do the surgery since it is so dangerous. I like you have been tormenting over the decision. So far Snuggles shows no outward symptoms either.

We may choose to do it if and when Snuggles starts exhibiting outward symptoms.

I know what you are going through, it has been a nightmare trying to know what is best.

I am sending you and your husband and Cloe my best wishes and prayers.

[abby]

Thank you all once again for taking the time to share your thoughts. We are grateful to all of you!

Ken, I am so happy to hear that Shiloh did well with surgery. I share your hesitation regarding surgery for Cleo...we are only considering it based on the recommendation of our well-regarded vet. Do you happen to have any names or practices for an excellent second opinion? (I'm not sure what "BC" stands for...still new; sorry! :o ).

Patti, thank you for researching and sharing Tipper's records for me. I am so glad to hear that Tipper has had no growth so far, and I'm keeping my fingers crossed for the next U/S to have a similar outcome. Even after just a three U/S so far, I absolutely understand the fear of monitoring...it makes even a risky surgery tempting. I'm glad to hear that your veterinarian supports waiting on surgery as no growth has been demonstrated. I expected ours to recommend the same course, and was surprised that he chose otherwise (why would we monitor in the first place, if the outcome of the U/S didn't affect the plan?) Tipper might be more like Cleo than I realized at first...she, too, is suspected to have the rare combo of a pituitary and an adrenal tumor. I wonder if the pituitary tumor could affect our adrenal tumor in some way, or if they truly are just completely separate events that happen to fall upon the same system? Hmm...

Beaglemom, I'm sending good thoughts to Snuggles, and thank you for your wishes and prayers for Cleo! I'd share your hesitation to subject Snuggles to this risky surgery as well, especially since Snuggles is asymptomatic. As my husband and I consider both options, if we choose to delay surgery and continue to do so, we will stop monitoring the tumor entirely by 14.5 or so, depending on Cleo's health (later if she remains in great health, earlier if her quality of life declines for other reasons). If only we had a crystal ball, or a clear line of when our parenting job shifts from focusing on both life-extending and quality of life measures, to just quality of life. Thankfully for both of us, this burden is on our shoulders alone as both of our dogs are asymptomatic and happy campers, and that's what matters the most.

And back to the original reply two days ago, I wanted to share Cleo's labs just in case its helpful. They are as follows:

***********
Low Dose Dexamethasone Suppression:

Pre-dexamethasone: 2.8
Post 4 hours: 2.6
Post 8 hours: 2.2

High Dose Dexamethasone Suppression:

Pre-dexamethasone: 3.6
Post 4 hours: 4.3
Post 8 hours: 2.6

Veterinary interpretation: HDDex failed to suppress, confirming HAC but not discriminating as adrenal tumors and some pituitary tumors fail to suppress. With bilateral adrenomegaly, it is possible that she has both adrenal and pituitary tumors (Abby's note: Cleo's left adrenal is slightly enlarged but of normal shape; her right adrenal is more abnormal and appears to have a mass effect).

Ultrasound veterinary notes, in regards to the area in question:

Left adrenal: There is borderline increased width (7.8 mm) with normal shape and layering, but mottled echogenicity with multiple hyper echoic regions.

Right adrenal: Moderately increased with to the caudal pole (1.2 cm) with loss of layering. The cranial pole is normal to decreased size (5.8 mm). There is no vascular invasion as assessed by color Doppler.

************

Again, thank you to all who are sharing your feedback on our girl!!

Wags from Cleo and thanks from her parents,

Abby

[Trish]

Hi Abby

Sorry I am late to your thread but here I am now and happy to share anything I have learned from Flynn's journey with adrenal tumour. He did have surgery to remove it and his invaded his vena cava and was on the right. His was a pheochromocytoma and he had negative cushings tests. All bad things, but he has done remarkably well with no sign of recurrence now 15 months later. It was an easy decision for me as he was not well and we had to do something. Unfortunately he had to have more surgery in November from a liver mass that was unrelated to the adrenal tumour but is doing well from that too.

It is a big decision for the surgery, but like Ken, I am a major believer in surgery if it is safe to proceed. I look at it that 4 dogs out of 5 get through this surgery just fine. But in saying that if my dog was asymptomatic and it was small like Cleo's is than I might be inclined to monitor for a while. I say this because Flynn also has a 1cm nodule on his remaining adrenal. But it is not growing too fast and we have had the benefit of the surgeon eyeballing it twice during his two surgeries over the last year or so. So we know it is most likely not a nasty one. Why does your surgeon want to go in and get it now? I can understand doing it before the dog gets older and develops new problems which could make surgery more risky, but is there anything about the look of the tumour on the scan that makes them suspect it is nasty?

Thanks Lori for posting the list of questions, I hope that is helpful for you when making your decisions.

Trish

PS BC = Board Certified, ie this surgery should only be performed by very well trained veterinary surgeons that have undertaken the appropriate trained and passed all their exams!

[Skye]

ahhhhhh i have been accused of being an over protective pet parent.....lol little do they know....sometimes it is forgotten that WE know our pets behavior best....they may know health, however we can predict how they may act. I would discuss at length if necessary and state your reasons as to why your concern with this. The incision is frightful....if you have not been warned. I am parent to minpin girl. and I too was called in by the ER hospital to be with my girl. She was continously restless even on her drip. Only time she would rest was in my arms. AND even after her adrenalectomy she would not rest. She was ready to be back with me. And once back with me she was in my arms and not ever once out of my sight. I was blessed as she did not mess with her incision at all. Onesies help but we didnt even need that. It is a high risk surgery. AND recovery is risky as well....AND risk if you dont do anything. It is a terribly difficult decsion to make. I cried every ocean full of tears over all this. IF the recovery is what is holding you back.....there MUST be a way some exception that can be made at UC. Nothing is impossible. Let me know how I can help if at all. Will be thinking of you.

[Skye]

i would ask how many performed, how many successes how many complications
and what they have for emergency situations during and after surgery