Adrenalectomy or medical management?

[Nutmeg]

My dog....a much loved "bully" mix has had Cushing's symptoms for a few months. She is thirsty, pees a lot, fatigues easily and appears to be aging quickly. She was a foster dog I adopted. I have had her for 4 yrs.....thought she was about 2 when I got her. I thought she was 6 or 7 yrs.....vet today said maybe 9-10 but we really don't know. Until she started having Cushing symptoms she acted like a pup. Initial tests revealed a very dilute urine. Went to the vet internist today for an ultrasound which revealed a large adrenal tumor which appears well encapsulated. BP was 250 ( started on BP Meds today)We will do more extensive lab work but I must decide whether to opt for an adrenalectomy or manage with trilostane. I do not want to use Lysogen. Very concerned about her having an adrenalectomy. Any "good" reviews out there? I will take her to UGA vet school if we decide on the surgery. Thx!

[Squirt's Mom]

Hi and welcome to you and your baby girl! :)

Thank you for giving her a loving home first and foremost! I only have a second right now but wanted to give you this list of questions one of our members worked up when in your same shoes with her boy, Flynn; tho they were dealing with a different type of adrenal tumor, the surgery is identical.

Questions to consider and ask the surgeon when facing an adrenalectomy
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.

You can read Flynn's story here - http://www.k9cushings.com/forum/showthread.php?t=4242&highlight=Flynn

Hugs,
Leslie and the gang

[Nutmeg]

Thank you! I did find those questions after I posted and they are so appropriate. I am leaning towards the surgery pending all the labs. If there are no contraindications I think we will go that route. There is such a risk of complications however, I want to talk myself out of it. We have already noticed such a decline in her quality of life. We adore this girl.......cannot imagine seeing her continue to lose her enthusiasm for life. If a "cure" is possible I think we may take the risk......terrifying as it is.

[molly muffin]

Welcome to the forum. It is very important that the bp come down and be controlled prior to any surgery if you opt to go that route.

I'll see if Trish is around somewhere and can pop online at some point. She is flynns mum.

[Trish]

Hi there! Thanks Sharlene for sending me a heads up!

I can give a good review, my dog Flynn had right adrenalectomy at age 11, he is a fox terrier mix and a rescue also. He is still trucking along and it is his 3
Year anniversary in a few weeks! He is 14 1/2 now, I remain very pleased I had it done and am absolutely sure I have had this time with him because of the surgery. But I agree with you, it is terrifying making the decision to operate. If I was you I would be seeking out a board certified surgeon who has done plenty of adrenalectomies and discussing it with them. Your girl is symptomatic, that BP definitely needs to get under control.

It sounds like it might be a different type of adrenal tumour than Flynn, he had a pheochromocytoma, he had BP issues and complications from that but tested negative for cushings. With such positive cushings signs in your dog, sounds like it might be a functional adrenocortical tumour. Did your IMS give any indication that is whT they think it is? In our case trilostane would not have helped Flynn, but there have been others on here that opted for medical management and you will be able to do searches for adrenal tumours and find them. Happy to answer any questions you may have and will keep an eye on your thread. I honestly think the worst time was figuring out the diagnosis and getting a plan in place, once you have done that and have a path forward it becomes a lot easier! Good luck :)

[Nutmeg]

Thank you so much Trish. The Internist thinks it is a functioning tumor. Having all labs done next week. Initial tests revealed liver function enzymes were normal although ultrasound revealed mildly enlarged liver. Put on BP Meds yesterday. Going to have weekly BP check. UGA highly recommended for surgery. Internist said tumor is large but appears contained and not involving renal vasculature. She hinted that surgery may be a good option but certainly is risky.....very scary. We see regular Vet next week who we really like and respect. Hopefully we can make the right decision for our much beloved Nutmeg. A "cure" with a lot of risk versus "management" that may work with miserable side effects.......