New England-Need to Find a Well Qualified Surgeon - Pheochromocytoma

[merry2day]

Hello Everyone - our 7 (almost 8)-year-old catahoula Jack was diagnosed with a pheochromocytoma after his heart beat and BP suddenly accelerated this past Wednesday, and we rushed him to the hospital. An ultrasound on Friday showed a 5- by 7- cm mass on his right adrenal. He is now home and on medications to control his BP and prepare him for surgery. Until this happened, Jack seemed 100% healthy--he's a very active dog. We are considering surgery unless we see clear signs cancer has spread. Can anyone recommend an excellent surgeon in the New England states? We hope to interview surgeons on Tuesday and Wednesday next week. We are located in NH so we have options within a couple hours drive: the surgeon at the smaller facility that diagnosed him who is said to be experienced (we'll meet him on Tuesday), Blue Pearl Vets, Tufts, Angell Memorial, etc. Any recommendations are appreciated. Thanks!

[Harley PoMMom]

Hi and welcome to you and Jack!

Gosh I am sorry for the reasons that brought you here but so glad you found us.

We have members whose dogs have/had a Pheochromocytoma and also went on to have a successful adrenalectomy. I am sure they will be along shortly so in the meantime I will provide links to a couple of their threads:Flynn 11 y/o Foxie Cross - Right adrenalectomy, 3rd Dec 2012 for Pheochromocytoma (http://www.k9cushings.com/forum/showthread.php?t=4242)

Meet Kaibo :) 6 y/o toy poodle - Diabetes & adrenalectomy (http://www.k9cushings.com/forum/showthread.php?t=4648)

One of our members, Trish (Flynn's Mom) has made a list of questions for pet parents that are considering an adrenalectomy for their furbaby, 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.

I just did a quick search on the ACVIM website for Internal Medicine Specialists in NH and found Veterinary Emergency, Critical Care & Referral Hospital which has gotten good reviews, here's a link to their web page: www.veccnh.com/Internal-Medicine.cfm

Tufts is known as a prestigious hospital but has gotten mixed reviews: http://www.yelp.com/biz/tufts-veterinary-emergency-treatment-and-specialties-walpole

Having a vet that is experienced in adrenalectomies is very important.

I'm sorry that I couldn't be of more help but my experience with Pheo's is zilch.

Please know we will help in any way we can, so do not hesitate to ask all the questions you want. ;)

Hugs, Lori

[beaglemom3]

Hi,
I am sorry to hear Jack has a pheo, my dog Snuggles who is 15 years old also has a pheo in his right adrenal gland. Due to his age and the type of surgery we opted not to go through it but his tumor is smaller than Jacks at this point, and so far Snuggles is not exhibiting any outwards signs, and his bp is still good. Jack is being affected by it now so I understand the need to go for the surgery.
But I tormented over the decision whether to go for the surgery or not for months, it is not an easy one to make, but if Snuggles was exhibiting signs I think it would push me into going for it too.

My thoughts and prayers are with you and Jack for a successful surgery and quick recovery.

[Trish]

Hi

Flynny had a pheo... it was also in his right adrenal and invading into his vena cava. Just to give you a whole lot of hope he had his removed now 21 months ago and on the whole has done really well. He also had the high BP and had to have phenoxybenzamine to stablise it before his surgery. He is still on anti hypertensives to keep it under control.

Sorry not much help on locating a surgeon as I am not in the US. But you do want one who is board certified and has done a lot of adrenalectomies. You also need to make sure there is a specialist anaesthetist as they can have BP swings when removing these tumours as it messes with their catecholamines like adrenaline.

You may have seen these but have added a couple of links I have found helpful.

http://www.vsso.org/Adrenal_Pheochromocytoma.html
http://veterinarycalendar.dvm360.com/pheochromocytomas-dogs-and-cats-proceedings?id=&pageID=1&sk=&date=
http://veterinarycalendar.dvm360.com/anesthesia-dogs-and-cats-with-endocrine-disease-proceedings

Here is a little summary of some research articles:
Research Articles
In a study of 52 dogs that had surgical removal of adrenal tumors by Massari et al, factors found to negatively affect prognosis included size of the tumor being greater than 5 cm, metastasis (obviously), vein thrombosis and combining another abdominal procedure with adrenalectomy. The median survival time was 953 days with 65% of patients surviving greater than 1 year after surgery. The intraoperative mortality was 2% and the perioperative mortality rate was 13.5%. Dogs with large adrenal masses (>5 cm) had a median survival time of 156 days and were more malignant in behavior. Although this study showed a poorer outcome with caval tumor thrombosis, two other studies did not show this to be a negative prognostic factor (Kyles and Schwartz). Caval tumor thrombus is also associated more commonly with pheochromocytomas, right-sided adrenal gland tumors and large size seems to increase the incidence of thrombosis (according to Massari).

In a study of 40 dogs by Kyles, the short-term mortality rate was evaluated in regards to the presence of caval tumor thrombus. Reportedly, tumor thrombus was seen in 25% of all dogs. Eleven percent of adenocarcinomas had tumor thrombus and 55% of pheochromocytomas had tumor thrombus. As mentioned there was no difference in the perioperative death rate regardless of presence or absence of tumor thrombus. The perioperative death rate was 21% for adenocarcinomas and 18% for pheochromocytomas. Previously, pheochromocytomas patients have a high perioperative mortality rate, but the addition of protocols that include administration of high doses of phenoxybenzamine (as high as 2.5 mg/kg twice daily) have reduced the death rate.

Swartz summarized the prognostic factors and survival of 41 patients undergoing adrenalectomy for adrenal tumors and she reported a 22% perioperative mortality rate. Overall, the median survival time was 690 days. Factors influencing shorter survival times included perioperative weakness, lethargy, decreased platelet count, increased BUN, increased clotting times (PTT), increased AST (liver enzyme), low potassium level, profuse bleeding during surgery, and the need to have a kidney removed at the time of surgery.

Hope this helps, if you have any questions, ask away as a few of us on here have had this problem with our pups!
Trish :)

[merry2day]

Hello Lori, Vicki, and Trish,

Thanks so much for the advice and sending your kind thoughts so quickly. All of this information is tremendously helpful as we look for the best doctor and facility to take care of our Jack. Overall he is doing well, though restless at times and obviously feeling the effects of the medication and the illness. He had a nightmare last night, but today he played a little, slept in the sun in his favorite spots, waded in our pond, and enjoyed his dinner. We are getting tips on surgeons to interview from a couple local vets, and I'm also exploring all the resources you provided. We are eager to start speaking with doctors on Tuesday, using the info you provided. I'll let you know how it goes. Thanks again! Your positive energy has really helped us today and lifted our spirits.

Mary

[molly muffin]

Hi Mary and welcome to you and Jack.

While I have no experience with pheo's we have had members such as Trish who have gone through it successfully. The key seems to be getting that BP to a good point so they are ready for the surgery and finding a surgeon who has done many and I mean MANY, successfully. I'd want someone who does them fairly regularly with successful outcomes. Make sure they are aware of the potential for blood clots and are clamping off so that this is less likely as it is often the post op period where things can go dicey, so you want a good recovery team too. That is why the more successful pheo surgerys they have done the better. They are aware of anything and everything that is possible and prepare for it the best they can. This increases the odds of a successful surgery I feel a great deal.

I think the list that Trish has prepared for members is a good one and arms you to go in and talk to the surgeons and give them a good interview.

We'll all be anxiously awaiting word.

Sharlene and molly muffin

[Trish]

Hi - checking in to see if there is any news on Jack, hope he is doing well on the BP meds and you have narrowed down the search for surgeons :)

[merry2day]

Hi Trish (and everyone who has been so kind),

Jack is doing very well on his blood pressure medication. He has enjoyed an ordinary fun-filled week since he was released from the emergency hospital. It is actually hard to believe that he is so sick. We considered a number of facilities and surgeons, and per our regular vet's advice, we are taking him to Tufts tomorrow for a consultation. We're armed with all the questions and info you provided. I'll let you all know what they discover and what we decide about his treatment. We are thinking positive thoughts! Thanks so much - Mary

[Trish]

Hi Mary

How did it go at Tufts, love to hear a progress report. Hope you got good news and a plan to move forward with. I think this is the hardest part, once you have a plan you can work towards it with a bit of purpose! I am thinking positive thoughts for Jack too! :)

[merry2day]

Hi Trish, Lori, Vicki, and Sharlene,
Sorry for lack of updates! Everything moved so quickly from Monday onward. I am happy to say that from our perspective we had a few miracles.

On Monday we met the surgeon at Tuft’s. After reviewing Jack’s history, they said they could operate as soon as Tuesday. This was a bit quicker than we anticipated, but we were impressed with the care team. Jack is my husband’s first dog (Jack was our wedding present to each other and we loved him even before he arrived) so ultimately he made the call to go ahead and trust the doctors. I really tried to stop worrying about what can go wrong but it wasn’t easy, especially since the surgeon made sure we understood the gravity of the situation. We did not expect to leave him behind on Monday so it was an emotional time for us. We did not sleep on Monday night, and we waited anxiously for word on Tuesday.

Jack's large adrenal mass was adhered to, but did not invade, the caudal vena cava. The right adrenal gland was removed and due to its close association with the right kidney’s vasculature, the right kidney was also removed. Jack did need a blood transfusion, and he recovered in doggy ICU where his vital signs, comfort, and urine production were closely monitored. (Lived through the surgery – Miracle #1!) We chose not visit him, as hard as it was to stay away, because we knew that Jack would expect we would be there to take him home. We stayed in very close touch with his care team via phone. Other than periods of elevated heart rate, Jack had no major post-operative complications (Miracle #2). Today—Friday—we brought him home! (Miracle #3) The biopsy report is still pending and we’re hoping for a home run.

He is a bit subdued on pain medication, and we are giving him antibiotics and carefully monitoring him. In a week, he’ll need a blood pressure check, an electrolyte panel and an ACTH stimulation test. In two weeks he’ll have his sutures removed, and he’ll need a kidney panel.

Jack is a very boisterous and strong willed boy. He has lost some weight, but we’re pampering him with his favorite foods. Hopefully he’ll be a little better every day. His 8th birthday is October 5. He loves to play in the hay wagon, so we’re going to give him a bale of his own to pull apart and make a nest. (We live on a farm). Right now he’s watching TV with my husband and dozing on the ottoman. So- when we left him on Monday we worried he might not make it through the surgery, and now the family is back together.

Thanks to you all for your encouragement and the incredibly helpful information. I’ll let you know how his recovery continues. We’re hoping for no emergencies since we live an hour and a half from qualified help.

Cheers!
Mary

[Squirt's Mom]

Oh Mary, what a whirlwind week you have had! I am so very glad that our sweet Jack came through this surgery and i pray he is on the road to full health again. Please keep us updated and know we are holding you all close in our prayers.

Hugs,
Leslie and the gang

[lulusmom]

Oh my, how did I miss this wonderful news? I am thrilled to hear that the surgery went well and that your boy is back home with you. I'm with Leslie and will be keeping you all in my prayers. Please do keep us updated.

Glynda

[molly muffin]

Wow! I can't even imagine how nerve wrecking the experience must have been for you and your husband, when everything moved into over drive.

I'm so glad to hear that Jack made it through surgery and is home and recovering. I do hope the recovery will be an easy one. I know one of our other members, said that the recovery went very well for her dog and I think they do for most of them once the danger of those first 48 hours post op have passed and they are home again.

We'll all be watching anxiously for Jack updates! :) :)

Sharlene and molly muffin

[Trish]

Hi Mary

That is fantastic news!! Sometimes I think it is a good idea to get in there and just get it done. So pleased it came out OK and Jack is now home to recover in comfort.

Finger's crossed for the histology, even with not total clearance the dogs can still do very well for a long time!! He will be subdued for a while, it is great to see those improvements though, even though slow at first they always surprise me with their resilience. When dogs have a pheo the opposite adrenal gland is usually still working away so they do not need supplementing with steroids, but I presume they are going to do the acth just to check that all is well in that department. If it was not a pheo Jack could need some supplementation so if he was off I would get it tested sooner. I did that with Flynn but his was fine. They can also be prone to a touch of pancretitits as that organ can be moved during the surgery and it does not take too kindly to that, so something else to keep at the back of your mind if Jack was not continuing to progress. But hopefully nothing will go wrong and he will be marching forward with his recovery.

I will be looking out for updates too so hope all continues to go well, you are over the hard part now, the literature says that if they get out of hospital and home after the surgery they generally do well! (depending on histology) so I reckon you have all done very good!!! :)

[Squirt's Mom]

How is Jack doing?

[merry2day]

Hello Everyone,
Sorry for the lack of news. I am very happy to tell you that Jack is doing great. We returned to Tufts on 9/23 for him to get his stitches removed and for lab tests with their oncology department.

There were no metastasis noted on x-rays or biopsies obtained during surgery, and his labs were absolutely normal, with one exception. They think he might not be concentrating urine at an optimal level; we’ll need to recheck that. Unfortunately they could not rule out the possibility that microscopic disease was left behind.

Tufts reviewed some options for medical therapies with us, and I liked the sound of metronomic chemotherapy. Basically it’s a low dose pill chemo (cyclophosphamide and an NSAID) that we can administer at home that would hinder potential regrowth. Has anyone had any experience with that treatment?

After looking at Jack’s labs though they were concerned about the effect various medications could have on his remaining kidney. We’re going to consult with our local vet before we decide what to do. Another kidney check may be in order if we want to pursue it.

I’m disappointed because it seemed like a good proactive option, but we don’t want to risk damaging his remaining kidney. (The other potential treatments--such as Palladia—seemed targeted to actual tumors and more than he would need at this point.)

Tufts will see him again in 6 months (unless we decide to pursue the metronomic chemo) for bloodwork, urine, chest x-rays and abdominal ultrasound. In the meantime, we are going to love him a lot and hope for the best! Thanks again for all the good thoughts and support. We absolutely could not have hoped for a better outcome.

Jack says thank you too (here's his picture in his beloved hay wagon if you can see it)!

https://www.facebook.com/media/set/?set=a.10204252613130475.1073741828.1082342024&type=1&l=c89a150766

Kind Regards,

Mary

[Trish]

Hi Mary

Overall that is a good report! Our vets also discussed metronomic chemo as we had similar result to your histology where they could not guarantee there were not microscopic traces left. We decided against it with his liver and renal issues. They talked about Palladia for him. We decided not to and I guess in our case it was the right decision as here we are just about 2 years post adrenalectomy with no sign of recurrence. We scanned him 3 monthly for a bit, now out to six monthly but he has also had liver tumours removed so we are keeping an eye on that as well.

Jack has done great, you must be thrilled!! Amazing how they can bounce back from such big surgery :)

Awwww stink, I cannot see his photo! :)

So nice to hear the update!

[merry2day]

Hi Trish - Thanks! That's reassuring. We're hoping that Jack's outcome will be just as good. He rests so calmly now and then bounces around like a puppy at playtime. Looking back, we can see how anxious and uncomfortable he was this summer before we knew what was wrong.

Here's another attempt for a picture:
http://websites.networksolutions.com/share/scrapbook/61/613979/Jack.jpg

We and Jack are very happy and grateful!

[molly muffin]

Love jacks photo. He is very handsome guy and those eyes are so alert and inquisitive.

How is that kidney doing? Is urine concentration any better?

[merry2day]

Hi Sharlene,

All Jack's systems appear to be working well. :-) He'll see our regular vet next week so we'll get a better picture of his kidney function.

Ha! Tuft's described him as boisterous and determined! I think his crazy catahoula attitude has helped him bounce back for sure.

Mary

[Squirt's Mom]

So glad to hear Jack is up to some of his old tricks! He is a tough guy for sure!

[molly muffin]

They do say attitude is everything, maybe that holds true for dogs too. :) :)

Hoping for a good report next week!!

hugs

[Trish]

Hi Mary

I can see his gorgeous photo this time, how is Jack doing?? Hopefully he is still doing great!! Is he still on any meds??

Hope you have both had a great weekend, I bet your stress levels are finally returning to normal about now!!

Trish :)

[merry2day]

Hi Trish,

I am happy to say Jack is still doing well. We had to move his vet appointment (I want to talk to our local doctor and get a check on his urine concentration) so we don't have any new info yet. He isn't on any medication.

He's growing fur where he was shaved for his surgery, and he's back to his old self. He's frisky in bursts, yet relaxed and quite content to snooze. It's hard to describe but looking back he was anxious and restless over the summer before we knew he was sick. Now he's content and peaceful, His appetite is great - probably too good! LOL

Thanks to everyone who has remained so supportive and interested. I hope I can share good news for a long time to come!

Mary

[molly muffin]

What a great report. Sure seems like he is doing great now.
Hope the urine concentration is good and that he gets another great report from the vet.

Good job!
hugs,

[jas77450]

Happy for you and Jack.:)

[Trish]

That anxiety was probably the pheo secreting at times, darn things so much better out than in! Funny the things you notice in retrospect. Are they going to check his BP too? I know it is meant to settle once the pheo is gone, but Flynn's never did and stayed high so he had to go on permanent antihypertensives and he has done well on them the past two years since his surgery. His kidney function was also affected, well honestly they were not sure whether the proteinuria was due to his high BP or his IBD... but whatever he has also remained on his benzapril for the renal protection that drug gives.

I will be looking forward to the next update on your Jack and I am sure we will be hearing good news for ages and ages!! x :)

[merry2day]

Hi Everyone,

A quick update: Jack's BP is normal and his urine concentration is nearly in the normal range, a little better and no worse than before.

Tufts will check him again head to toe in March, so we are going to carry on as planned without additional medications at this time.

Our big boy is proud that he has regained the 10 pounds he lost during his ordeal :-) despite being on a lower protein "senior" diet.

Happy Thanksgiving and positive puppy wishes to you all!

Mary

[My sweet Ginger]

I'm so happy to read this update on Jack.
A fantastic job you two. :);)

[Trish]

Fantastic with the normal BP!! Sure sign that sucker pheo is gone!! :) Flynn's never did and he remains on antihypertensives.. but at two years now I am used to it :) Nice you have a few months of relaxing before the next checkup!! Those checkup scans are a nervy time but so great when you get the good news afterwards! :)

[merry2day]

Hello Everyone,

I am happy to report that Jack passed his physical at Tuft's this week with flying colors. :) His pheochromocytoma was removed on 9/9/14 so we're more or less 9 months post surgery.

At this visit he had a CBC and chemistry blood work, a urinalysis and abdominal ultrasound. The results didn't raise any alarms; there's no metastatic spread as far as they could see. All indications are that he is doing well with his remaining adrenal gland and kidney.

Tuft's would like to see him again in 6 months for chest x-rays, an abdominal ultrasound, and bloodwork. Of course, we'll bring him in if we notice any changes before then. Last summer his coat and nose looked terrible, and he was panting a lot. None of that this year thank goodness!

Jack is officially 8.69 years old, and we are (cautiously) optimistic that he'll be with us for a long time to come. He is taking advantage of his status as miracle dog, sleeping in the middle of my herb garden in the afternoons. We are so soft hearted where he's concerned; we just let him have his way!

I hope you and your pups are also doing well. Thanks for your support.

Mary

[labblab]

Oh Mary, thanks so much for coming back to post this great report! :)

It is wonderful to read such good news, and we hope you'll continue to drop by again to report on our boy Jack.

If you have a moment, perhaps you can drop in and visit this new member who is debating adrenal surgery with her Lab. Although probably not a pheo, still, you may have tips or suggestions or thoughts that she may be able to take into consideration in making a surgical decision.

http://www.k9cushings.com/forum/showthread.php?t=7258

Thanks, and don't be a stranger! ;)

Marianne

[Squirt's Mom]

Thank you for letting us know how Jack is doing...and especially glad to know how much he is enjoying his new lease on life!

[merry2day]

Hello Everyone,

I am happy to say that Jack is still doing well - he's the picture of health with no symptoms one year post surgery. His ninth birthday was October 5. He's busy helping new puppy Boone (aka Jack Junior) learn about life on the farm. He's surprisingly patient with the little one, and he's getting more exercise these days for sure. Hope your pups are also doing well. Enjoy the holidays!

Mary and Jack

[Harley PoMMom]

Hi Mary!

Thanks so much for coming back and updating us about Jack, what a wonderful update it is!!! So glad he is doing so well....and a belated Happy Birthday!!!

AWWWW, And congrats on the new addition to the family, looking forward to seeing some pics of Boone!!! (hint ;):D)

Hugs, Lori

[molly muffin]

What a great update!!! and now 9 years old too !

Happy belated birthday Jack!

[merry2day]

Boone says hello! http://www.synergivity.com/boone.html
I hope you can see him. He sure keeps Jack busy these days!

[Harley PoMMom]

AWWW he sure is a cutie!!!!

[molly muffin]

Oh definitely adorable. Love that he is keeping Jack busy. :)

[Squirt's Mom]

What a great update, Mary! I am so glad Jack continues to do well and very happy to know he is enjoying his new buddy so very much. Boone is a doll and those eyes! Gorgeous!