Adrenal tumor - possible surgery at UTK?

[krogerss]

I have a Westie that just turned 10 and has a suspected malignant tumor on her right adrenal gland. It was discovered through an ultrasound. She is displaying some symptoms of Cushings, but my main question at the moment is regarding this tumor.

A little background info - I took her to a vet specialists clinic to have an ultrasound in February 2016 at the referral of my regular vet. The ultrasound was "unremarkable" and no masses were observed. I had this done as a precautionary measure due to her ALP climbing. Anyways, this past July she got really sick due to IBD flaring up and primarily a severe case of pancreatitis. She was hospitalized for a few days and during this time she had another ultrasound. This mass was discovered at this time. I don't know the size of it, but they say it appears to be starting to invade the "vena cava" a bit. Also, it is their opinion that the tumor is inoperable due to it being so close to a main artery. If it was on the left gland, it might be a different story, but their stance is that there is nothing they can really do about it. The Dr mentioned that a chemo drug could possibly be tried, but she is afraid of the side effects that may occur and afraid of the pancreatits flaring back up. A few days ago on a follow up visit, she had a focal ultrasound and the mass has grown, but only by about a millimeter or so. They says these types of tumors are usually fast growing, but hers is a little unusual being on the slower side. Since then, I have taken her to another vet specialist, an oncology doctor, for a second opinion. This doctor looked at the images from the previous ultrasounds and she is in agreement with the initial diagnosis. They do "kind" of suggest doing an ultrasound themselves though, because they say can get a better look instead of just viewing static images. Anyways, I am looking at maybe doing this or even looking for another specialist. I have been to the only 2 in my immediate area (Nashville, TN), but thought looking a little further away if it would be recommended. Anyone have any thoughts, opinions, etc? I am kind of still in shock over this and am not sure what to do or what I can do. Thanks so much in advance for your time and for reading this.

[dsbailey]

Welcome,

I'm rather new here and don't know much about adrenal tumors. You posted late but tomorrow you'll be getting replies from some very knowledgeable and caring people. I've heard discussions here of some top specialists and hospitals / universities. You're not alone and others will be along in the morning.

Darrell and Lolita

[Joan2517]

My Lena had an adrenal tumor close to her vena cava as well. Since she was 14 at the time, my vet did not recommend putting her through the operation and even though she died from complications due to Cushing's a few months later, I still would not have put her through it at her age.

There are members who have had the operation done who will be by to let you know of their experiences.

Good luck to you and your darling girl...

[krogerss]

Thank you, I appreciate it. Joan, I'm really sorry to hear about Lena. It really, really stinks to see our pets go through these things. I must say I feel pretty helpless with this at the moment. Especially since these vet specialists I've been to are telling me that surgery really isn't an option. With that being said, I don't even know if I could make the decision to do the surgery if I was to find someone because of the risk. It just sucks but I'm open for any suggestions or questions. It really means a lot to be able to reach to you all. Thank you.

[judymaggie]

Welcome to you and your pup! I am sorry for the reasons that caused you to seek us out but, hopefully, those folks with experience with adrenal tumors will be along to offer personal guidance. Should you seek out another opinion, I did want to give you the link to a post that contains questions for you to ask the surgeon as well as those for you to consider:

http://www.k9cushings.com/forum/showthread.php?p=193189&highlight=adrenal+tumor#post193189

Also, a close friend of mine who lives in Georgia has been taking her dog to UT Veterinary Hospital in Knoxville -- her dog has bladder cancer and went there for advanced diagnostics and now chemo. She has spoken very highly of their professionalism and caring attitude toward her and her dog. Just throwing that out there as a possibility for another opinion -- I do not know how experienced their surgeons are with adrenalectomies but you could certainly find that out.

[Harley PoMMom]

Hi and welcome to you and your girl from me as well!

I sure am sorry for the reasons that brought you here but glad you found us and we will help in any way we can.

An adrenalectomy on the right adrenal gland is generally a little more difficult than the left, mostly because of the proximity of the pancreas and some blood vessels. Have they determined if the tumor is functioning, non functioning or a pheochromocytoma?

I'm including a link to a thread on our Archives that details the experience of one of our members and her dog, Sammy, who underwent surgery for a pheochromocytoma of the right adrenal gland: http://www.k9cushings.com/forum/showthread.php?t=1041

Another one of our members, Trish, had an adrenalectomy of the right adrenal gland performed on her sweet Flynn so here's a link to that thread also: Flynn 11 y/o Foxie Cross - Right adrenalectomy, 3rd Dec 2012 for Pheochromocytoma (http://www.k9cushings.com/forum/showthread.php?t=4242)

Trish was also kind enough to prepare a list of questions for members contemplating this type of surgery:
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.


Trilostane/Vetoryl and Lysodren/Mitotane are the two drugs generally prescribed for canine Cushing's disease and both are considered to be chemo medications. These two drugs act very differently; Trilostane inhibits with the production of cortisol, while Lysodren erodes the layer of the adrenal glands that produce cortisol.

Dogs with adrenal dependent hyperadrenocorticism (ADH) require high doses of Lysodren because these types of tumors are resistant to Lysodren. This than requires a much higher loading dose of Lysodren which can make the chance of an Addison's crisis more likely, and is the main reason when treating ADH vets prefer using Trilostane.

I have to rush out of the door right now but I will try to post later and I'm sure the others will be by soon to welcome you both.

Hugs, Lori

[krogerss]

Thank you for the feedback. These are certainly good questions as well. However, I'm a little baffled that these doctors are telling me that surgery isn't an option for her. I know every case is different, but I believe I have a lot of questions for them. To reiterate, the internal medicine Dr is telling me this. She is with "Nashville Veterinary Specialists." I also had an oncology doctor with "Blue Pearl Veterinary Partners" tell me the same thing based on the images from the ultrasounds done at NVS. However, Blue Pearl suggests doing an ultrasound themselves to more accurately verify this. I just see a lot of folks having this procedure done. With this being said, I don't know that the surgeons at either place has been consulted. Should I ask them about this? Will an ultrasound provide the necessary detail to conclusively draw their conclusion? I don't know the type or size of the tumor, but it has grown by about "1mm" over the past 6 weeks. My dog is not currently being treated medically for the mass or any Cushings symptoms; they haven't even suggested it at this point. She doesn't seem to be having too many cushings symptoms at the moment, but she does pant some like she's heat sensitive and her appetite is pretty huge. The appetite may be due to the medicine though. Her blood pressure over the past two months has been in the high end of "normal." (156) I just hope they're being totally honest with me and not sugar coating anything. Maybe I should explore what options the University of Tennessee may provide as suggested. I'm not too terribly far from them. Anyone else in TN or close by and have any recommendations? There are indeed board certified surgeons at the two places I've already been, but maybe they don't have much experience in this procedure? One thing of note is that my dog Sugar got real sick back in July and was hospitalized a couple of different times for a few days over about a 1 - 2 week period. She has IBD that flared up, but the main issue was a severe bout of pancreatitis. Currently, she is having to take a steroid called "Budesonide" every day to keep the IBD in check. Thanks again for your time and thoughts.

[molly muffin]

You definitely want to discuss options with a board certified surgeon who had done MANY of these adrenalectomies successfully. It might be that it is too far into or the exact location is what is making the surgery not an option, they need to be clear as to why they think it isn't an option.

The University of Tennessee has a lot of of experience with cushings and that is where I would probably go if possible.

[krogerss]

I know this is a shot in the dark, but has anyone ever had an adrenalectomy done at UT College of Veterinary Medicine (Tennessee)? Thanks.

[labblab]

Welcome back to you! I just wanted to let you know that I've merged your question about UTK into your original thread and also edited your thread title. In this way, it will be easier for folks to read about your dog's specific situation, and respond with their thoughts and suggestions.

Marianne

[molly muffin]

We didn't have an adrenal tumor and I'm not sure if we have anyone currently active that has used the University of Tennessee. I am sure that we have though. I know there was a FB member whose dog had surgery at UofT, adrenalectomy.

Did you speak to a surgeon? Do they now think it is possible to do surgery?

It isn't always possible and in that case, you would do regular ultrasounds monitoring the tumor and size and treat with medication, although it can be tough to get good control. It can still be helpful though.

[puhmuckel]

I am very sorry to hear that you are faced with an adrenal tumor in your dog. A regular Board Certified Surgeon cannot operate on an adrenal tumor. You will defiantly have to go to a University teaching Hospital in your State and you say that is in TN.

That is how I lost the love of my life, my best friend and the one I still compare all the others to. I took Winki to the Veterinary Specialists in Berkeley and they did an US after Winki suddenly became sick and refused to eat. I was referred to the University of California in Davis and rushed him up there for a CT scan and possible surgery. The tumor was invading the vena cava up to some point and it was thought that he had a pheochromocytoma. I waited for many hours for all of the specialists to come together and give me the news.

They told me that Winki was too unstable to undergo a CT scan at that point. Told me that they would stabilize him and try the risky surgery when he was more stable....but I knew it was not the right thing to do.
He was euthanized within the hour. He was suffering and I had to let him go. I remember the MD telling me if that was her dog , she would have done the same.

He was my everything and money was no issue and I as an ICU nurse could have taken care of him, but the tumor was malignant and had done too much damage.

I had an autopsy performed and due to the pheochromocytoma, he had lost most of the function of his heart, lungs and liver and had a second smaller tumor on the other adrenal gland as well.

RIP Winki 2002-2012