Pheochromocytoma and Cushings operation advice

[Hannah1108]

Hi everyone,

My almost 9 year old shih tzu has been diagnosed with a pheochromocytoma (tumour on her left adrenal gland which has grown into her vena cava). We've just had some test results back and she's also got cushings disease, probably from the pheo releasing cortisol steroid but also possibly because she has a small brain tumour in addition which is causing the 'good' adrenal gland to release it.

We've been referred to a specialist oncology and soft tissue surgeon who is very experienced but he said himself it's a very tough decision to make as the surgery is high risk and recovery equally critical, although he does seem to think she has a reasonable chance of pulling through. There is also a small risk that even once the pheo is removed, she could still have cushings IF it's not the pheo producing the cortisol. Or that the tumour has broken off and could potentially have started to spread to lungs/liver already.

In herself she seems fine. She is on antisickness meds (the only reason we took her to the vet initially) and beta blockers to prepare her for surgery, but is generally very happy and you'd never really know anything was wrong, although we are aware of the risks of possible rupture/deterioration if not operated on.

The decision we are now trying to make is whether to put a 9 year old dog through massive surgery, or to leave her and let her live out her life (whilst it's still of a good quality). But we don't know how long that will likely be. So we were looking for some opinions from others who may have been in similar situations.

Thank you for reading, sorry it was so long.

[dsbailey]

Hi Hannah,

I see that nobody has posted to you yet but I want you to know that you're not alone. I know that that there a lot of people here that know much more than myself about (ADH )adrenal. I know a bit about cushings but mainly the pituitary kind. I'm sure someone that has been in your shoes will come along soon and pick up where I lack. I have sent out a few messages to people that I would trust with my dogs life to look at your post. Your situation is complex and the decisions you make shouldn't be made without exploring every avenue of thought. You stated there was Vena Cava invasiveness which is very serious, as stated I don't know much or if there or grades of invasiveness but I do know that comes down to very serious decisions. I'll look in tomorrow and see who's responded but I do want you to know that you've come to the best place possible to find the answers.

Darrell and Lolita

[labblab]

Hello Hannah, and welcome! Many thanks to Darrell for posting to you last night, and as he says, I'm sure there will be other folks joining you here today. I am going to start you off by giving you a link to another member's thread wherein you'll find a good introductory discussion of surgery to remove a pheo. Hopefully it may answer some questions, and it also may raise some new ones for you. So do take a look, and then get back to us with your thoughts, OK?

http://www.k9cushings.com/forum/showthread.php?t=6578

Marianne

[Harley PoMMom]

Hi and welcome to you and your girl!

I'm not intimately familiar with pheo's so I have no words of wisdom or advice to share but I am including a list of questions that one of members, Trish, (her Flynn had an adrenalectomy) compiled for owners that have decided with surgery.


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.

Hugs, Lori

[Hannah1108]

Thank you so much for your kind words and advice. Ill definitely be having a read of those other threads you've sent links to.

There are different severities of invasion of the vena cava and thankfully we THINK that hers isn't that big, although they don't yet know (and won't until operating) how far down the vena cava it is attached. If attached only at a small area, the operation will be much easier than if it's attached the whole length of the tumour.

It's good to get other people's opinions on what they would do if it was their little dog :'(

[molly muffin]

Hello and welcome from me too.

Its a tough decision to make because it is a risky surgery, but if she comes through surgery and recovery okay, then as a shih tzu she can have many good years of life ahead of her. Cushings if she does have a pituitary tumor, can be controlled with medication, but she may not need that as the tumor and invasion could be causing the elevated cortisol levels.

Alot depends on how the surgeon answers the questions in the list that lori posted I think. How could a candidate is she for surgery (you said he thinks good) and the all important, what would you do if it where your dog is a good one .

[kaibosmom]

Hi there. I feel for you for having to make this decision. While my dod didn't have a pheo, he did have an adrenal tumour and we did do the surgery. His tumour was on the right side and we were very fortunate that it had not yet invaded the vena cava. We had a lot of support from this group and the questions posted earlier helped us as we met with the surgeon, etc. Kaibo was only 5 at the time so we felt that the risks were worth taking since he was so young. I do wish you well as you journey through this. The one thing I can say (and is likely what someone here said) you have to be ok with your decision. Know that you are making what you feel is the best decision for your pup. Know that you are following your instincts and heart and trying to do what is best for her. You have to be comfortable with the decision and accept what happens either way. You can't regret your decision and deal with the what ifs. It will drive you mad. So, ask questions, sit with the information, and make the choice that feels right for you and your little gal. Hugs and good luck to you. I'm not on here much but if you private message me I will provide any support or answers I can. Take care.

Nikki

[Hannah1108]

Thank you. Nikki, do you mind me asking how recovery was for your dog and the outcome for him? Her age is part of the worry, even though I know she could have a few more years. She is just so happy dah to day and really enjoying life right now that it seems such a. Risk to hand her over knowing I may not have her back although without the surgery she could have the vena cava rupture, not to mention the risks of spread of the cancer. So so hard to decide the best option.

[kaibosmom]

Hi Hannah. It certainly was a difficult decision and I feel for you that you have to make it for your sweet baby. Recovery was quite good for Kaibo, although I am a teacher and we planned the surgery for summer when I was off and could be with him 24/7. The incision was very large - pretty much all of his chest and then to the side, so like a "t" shape. He was in the hospital for a few days after and I don't remember if we were allowed to see him the first day. He was on prednisone for a month or so after. Once we weaned him off, he was great. A normal dog...for a while...he makes his own rules so he decided he should have Cushing's again about a year and a half later. I certainly am glad I was off to care for him and be with him all the time. I was able to put the heat and cold on the incisions several times a day, take him for short walks when he was ready, etc. It wasn't a fast recovery but it was an invasive surgery so I guess that is to be expected. If you have any more questions, let me know!

Nikki

[Hannah1108]

Thank you Nikki. I'm glad that the operation was a success for you and it's good to know what we could be in for if we do decide on going for surgery. X

[Hannah1108]

Does anyone happen to know if phenoxybenzamine is a drug that they would need to stay on to maintain the condition, should we not have surgery? We've recently cancelled the op she was booked in for as had heard some bad reviews and are looking to find a specialist elsewhere (have an appointment this week) but on cancelling the appointment with the last place, they have now said they won't provide the phenoxybenzamine. We can't seem to source it elsewhere as she only weighs 6kg and the standard size capsules are too big

[molly muffin]

You do need a prescription for it and it is used to reduce blood pressure which needs to be carefully monitored leading up to surgery, during surgery and after.

It is important to have a good surgeon who has done a lot of these and is an expert in the procedure so if you have any qualms about someone it is best to look elsewhere as you are doing.

[Hannah1108]

Hi,

I posted a couple of weeks ago explaining our situation and have had some really helpful responses. My 9year old shih tzu has a pheochromocytoma which has invaded her vena cava and she has cushings (probably from the pheo- a mass on her adrenal gland).

I met someone whilst at a vets appointment today and she mentioned that her boxer had a different type of mass invading the vena cava and the dog was having seizures before they had diagnosed the condition, by which time it was too late to operate. I'm just wondering if anyone else has experienced seizures with cushings or a pheochromocytoma as it would break my heart to see our little one go through this.

We are just trying to prepare ourselves for all possible outcomes if we choose not to have her go through surgery as the thought of handing her over at the moment is just so hard. She's in good health currently aside from sickness which is being controlled by cerenia.

Thank you.

[Squirt's Mom]

Hi,

I have merged your post about seizures into your baby's original thread. We like to keep all info about each pup in one thread. That way it is easier to look back thru the history for the big picture....it can also act as a sort of diary or journal for you as well so you can look back and see patterns, etc.

Hugs,
Leslie and the gang

[molly muffin]

I think that any time you have cushings, excess cortisol that you can possibly have seizures from it. Quite often though seizures have to do with a pituitary tumor but the vena cava is the major blood vessel going to the heart and can if it invades too much interupt blood flow which I would think could have and would eventually have an effect. Lack of blood flow could cause seizures I'd think but keep in mind I am guessing as pheo's aren't as common as cushings and I can't remember specifically a pheo dog experiencing seizures but I think that if left too long happen as the tumor continued to grow.

I know that isn't overly helpful, but I would definitely ask the vet surgeon or IMS about it.

[Hannah1108]

Hi everyone, I don't know if you remember shylas story and I hope I've done the right thing by linking this to my original post. She was diagnosed with pheochromocytoma in December last year. It was invading the vena cava and she presented with vomiting but was otherwise well. We've had a good few healthy months with her without going down the surgery route - she's been on anti sickness meds and phenoxybenzamine which seem to be helping her.

The last few weeks she's been really off of her food and has had a few accidents on the floor, she seems to have a sudden urge to go and can't hold it.

She's had a low dose Dex test and the results were slightly off (I will try and attach a photo). The vet said that the strange thing is that they seem to point to cortisol release linked to pituitary rather than adrenal, so we now don't know whether she could have two separate tumours.

We're not sure whether it's worth putting her under a general anaesthetic for a scan to identify the cause of the cushings symptoms. Or whether or not we should try veterol with her. If I manage to upload an image I would love to hear any of your views on the results and opinions on what steps you would take x x

[Hannah1108]

Hopefully these links work

https://ibb.co/fnG6Da
https://ibb.co/gR22mv
https://ibb.co/fZLBeF

[labblab]

Welcome back, and you've posted in exactly the right place. Your links work just fine, and I'll try to head back later on today to look things over more thoroughly. At a quick glance, though, I see why your vet has said that the LDDS results would be consistent with a pituitary tumor. A trial course of low dose Vetoryl might be worth experimenting with, except for the fact that her appetite is poor. You really don't want to depress it any further, and the Vetoryl might well do that.

I understand why this is a puzzle for you, and as I say, I'll try to return later on today. Hopefully, some other folks will have a chance to weigh in, too.

Marianne

[molly muffin]

Can they do an ultrasound without anesthesia? We never had to use any anesthesia for my dog for ultrasounds, so maybe that is an option?

[Squirt's Mom]

Abnormal test results per links posted:

Haemotology:

WBC (L) 4.11 5.05-16.76 x 10^9/L
Lymphocyte (L) 0.63 1.05-5.10 x 10^9/L
Eosinophil (L) 0.05 0.06-1.23 x 10^9/L
Platelet 559 (H) 148-484 x 10^9/L
Plateletcrit (H) 0.51 0.14-0.46%


Chemistry:

Lipase (H) 2131 200-1800 U/L


LDDS:
Baseline - 108 25.0-125 nmol/L
4 hr - 41.7 nmol/L
8 hr - 49.7 <=40.0 nmol/L (a)
(a) slight haemolysis in first and second sample

[lulusmom]

Hi Hannah and welcome back.

The adrenal glands of dogs with pituitary cushing’s have a constant oversecretion of cortisol whereas dogs with pheochromocytomas that are non-functional and secrete nothing or they could have episodic releases of catecholamines which are epinephrine and norepinephrine. Pheos share few symptoms with cushing’s but one of them that overlaps between the two is excessive peeing and drinking. I personally wouldn’t automatically assume that your girl has both cushing’s and a pheo, despite the positive LDDS test which would be interpreted as being consistent with pituitary dependent cushing’s. This test is highly likely to yield false positive results, which I believe would be possible with a pheo as a release of epinephrine can cause a major rush of cortisol. Having said all that, there is always the possibility that your pup has concurrent cushing’s as references I’ve read say that 10% to 12% of dogs with pheos in a few trials had concurrent cushing’s. I’m not sure the results of the blood chemistry would bear this out in your dog’s case however. Let me clarify that I am not a veterinary professional in any way, shape or form but have done a lot of research on blood chemistry, cbc and urinalysis interpretation as it relates to cushing’s and related disorders. Aside from a very negligible increase in lipase, which I don’t believe would raise any eyebrows on its own, everything else in the blood chemistry is within normal range which would be highly unlikely in a dog with cushing’s that has progressed enough to cause symptoms. Given that excessive drinking and peeing are the main symptoms, your vet should have done a urinalysis with a culture and sediment to confirm that what you are seeing is clinical polyuria/polydipsia and to rule out a urinary tract infection. Was this done and if so, can you please share the results with us?

With respect to the complete blood count, I believe the abnormalities can be caused by either cushing’s and/or a pheochromocytoma as all are indicative of a stress response to cortisol and/or epinephrine. I highly recommend that you ask your vet to go over the results with you. Every lab abnormality has to be interpreted in conjunction with other lab abnormalities, symptoms and physical presentation of the dog, so your vet is your greatest resource and because you know your dog best, you are an incredibly important resource for your vet.

Lastly, I want to mention that pheos can be quite invasive and malignant so if it is at all possible to have an ultrasound done, I think that would be a good next step and the best bang for your buck. I personally would want to know if this is an aggressive pheo. I hope this helps.

Glynda

[Hannah1108]

Thanks for your replies. I will ask about an ultrasound, she did have one on her stomach which is how what they think is a pheo was diagnosed. She didn't need anaesthetic for that.