12 year old dog with large adrenal mass, recent kidney failure

[ascamhi]

Hi my 12.5 year old dog Cloey went into kidney failure this past January. An ultrasound revealed a large adrenal mass 5cm x 3.5cm. Since January she has miraculously rebounded from the kidney failure. We just had a new ultrasound done and tree mass has grown. Just sent her blood panel out to U. of Tennessee and awaiting the results. I have no idea what to do. Surgery seems very risky, but the mass hasn't spread to any vessels yet. I would really appreciate your support and opinions. Thanks! Ashley

[Harley PoMMom]

Hi Ashley,

Welcome to you and Cloey! I have only a moment to post but I do have a few questions before I go.

How was the kidney failure diagnosed? Was a chemistry/CBC blood panel done and if so, could you post all values that are marked either H or L. What symptoms is Cloey displaying? Is she on any medications, herbs or supplements?

With the adrenal form of Cushing's surgery is the cure however this type of surgery is very serious and expensive. I'm including a list of questions that one of members created when an adrenalectomy is being considered:

Part I is for owners in the initial stages, when an adrenal tumour has been identified and they are considering if surgery is even an option for their dog.

Part II is for when surgery has been decided upon and what questions might help when they are discussing it with their surgeon.


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.

Hugs, Lori

[DoxieMama]

Hi Ashley,

Welcome to you and Cloey though I'm so sorry for the reasons you've joined us. Have you had any other testing done on Cloey or is this blood panel the first one?

I'm sorry I haven't much time to respond but wanted to welcome you and let you know that you are not alone! Others will be along to help support you and Cloey as you determine your options.

Shana

[ascamhi]

I probably have 20 pages worth of notes from my vet and the emergency vet haha. In January her kidney failure was identified due to her lack of desire to eat or walk very far. It may be easier for me to start with the current results and work backwards.

The blood panel went out hopefully yesterday to U. of Tennessee. This decision was made after a second ultrasound was done this past Friday and showed that the adrenal mass (left adrenal tumor) had grown from 5.05 x 3.77 cm to app. 5.4 x 3.85 cm without evidence of vascular invasion or metastasis. Her blood pressure was also taken with the average systolic at 134.

She is currently 12 and a half, she eats and drinks well, is happy to go on long walks. She is somewhat lethargic at times and her legs have given out a few times in the past few months. The adrenal mass was identified when she went into kidney failure and an ultrasound was done. She has recuperated really well from the kidney failure. She isn't on any medication for it and no longer requires subcut fluids. I do not know what breed she is since she was a rescue from when I was in the Peace Corps in Paraguay.

She is not currently on any medications, but she does take fish oil and wheat germ oil to reduce inflammation.

Her last blood work was done by my normal vet on April 15th. Her ALB = 3.2 g/dL, ALB/GLOB = .9, and BUN/CREA 25. Her creatinine is high at 2.4 mg/dL but way lower than it was when she went into kidney failure. Her BUN/UREA is also high at 59 mg/dL. Right now nothing else is flagged as high. In comparison on January 18th her BUN/UREA was 64 mg/dL and CREA was 4.3 mg/dL. So she definitely has impaired kidneys but has improved greatly.

Is there other testing that should be done while I wait for the blood panel? I plan to get a second opinion as well since I myself have not seen the ultrasounds, I just know the mass hasn't invaded any vessels and doesn't seem to have spread.

I am aware the surgery is risk, especially it appears the post-op. It appears to be a difficult choice to make because she has rebounded so well from the kidney failure. In addition I am curious if there may be any link between the two, because we never figured out what caused the kidney failure.

Thanks, looking forward to your thoughts!

Ashley

[Harley PoMMom]

What's the reference ranges for the creatinine? Since her creatinine did drop significantly it sounds like she had a sudden assault on those kidneys, usually with kidney failure the creatinine stays at a high level. CoQ10 has the potential to lower creatinine levels so you may want to discuss this with the vet.

Was the adrenal panel done for the purpose in diagnosing a functional adrenal tumor from a non-functioning one?

Is she spilling protein in her urine? One test that I would recommend is the SDMA from IDEXX website:
SDMA (symmetric dimethylarginine) is a renal biomarker specific to kidney function.

Link to info regarding the SDMA: [https://www.idexx.com/small-animal-health/products-and-services/about-sdma.html

I'm at work so I will try to get back later on. One thing I did want to say is, Bless you for giving Cloey a forever home, she sure is lucky to have you as her pet parent.

Hugs, Lori

[lulusmom]

Hi Ashley and welcome to you and Chloe.

Not all adrenal tumors are functional, meaning they don't over-secrete adrenal steroids/hormones. It's therefore quite possible that your vet wanted the UTK adrenal panel done to rule out a functional tumor. If it's a functional adrenal tumor, there will be elevations in one or more of the adrenal hormones assayed. Chloe's few symptoms are not exclusive to cushing's so that makes it difficult to determine if an adrenal tumor is functional. Does Chloe drink and pee a lot and frequently? Any skin or coat issues? Can you take a look at the last blood labs and tell me if the ALT, ALP, GGT and Cholesterol are normal?

Sorry for all the questions but I'm just trying to put Chloe's history together. It makes it a lot easier to provide you with meaningful information if we have all of the pieces of the puzzle.

Glynda

[ascamhi]

Cloey doesn't have any skin or coat issues. She does drink water and urinate, but I don't think it's that frequently. She has really always done that. How often would you define frequent?

From the bloodwork on April 15:
ALT = 42 U/L reference range 10-125 so normal
ALP is that the same as ALKP? If So her ALKP = 127 U/L reference range 23-212 so normal
GGT was done February 9 = 5 U/L reference range 0-13 so normal.
Cholesterol I am assuming is CHOL was done in February 9 = 167 mg/dL reference range 131-345 so normal.

The reference range for creatinine is .5-1.8 mg/dL and she is at 2.4 so high, but lower than when she was in kidney failure. In January it was 4.3 :(.

I believe the adrenal panel was done to diagnose a functional adrenal tumor from a non-functioning one.

Keep coming with the questions, I am happy to did through all of this blood work to understand it better.

Ashley

[lulusmom]

Thank you for your response, Ashley, and good job of keeping on top of things.

Your vet is probably in a conundrum as those blood values you posted as normal are usually elevated whether a dog has a functional adrenal tumor or pituitary dependent disease. Even if your dog's UTK adrenal panel shows elevations in any of the noncortisol adrenal steroids assayed, it will be a tough call to determine if a functional adrenal tumor is the root cause if Chloe has any nonadrenal issues, such kidney problems. I have provided a link below to a white paper by Dr. Rhett Nichols that clearly show that nonadrenal illness can cause increase in cortisol as well as noncortisol adrenal steroids. I've cut and pasted an excerpt below which I believe is very relevant to Chloey's situation. You may want to share this information with your vet.


ARE NONCORTISOL STEROID HORMONES ONLY ELEVATED IN DOGS WITH ATYPICAL CUSHING’S DISEASE?

In addition to the UK study, there are four other relatively large published studies that have evaluated multiple noncortisol adrenal steroid hormones (sex steroids and other cortisol precursors) and cortisol concentrations post-ACTH in dogs diagnosed with HAC (4, 5, 6, 7).

The diagnosis of HAC was based on results of history, clinical signs, routine biochemistry and urinalysis findings, assessment of adrenal ultrasound imaging, a positive ACTH response test and/or LDDST, and in some cases an endogenous ACTH level. In two of these studies dogs with adrenal tumors and dogs suspected of HAC but diagnosed with another condition were also included (4, 5). Overall, when the information from all these studies is combined, 76 dogs were diagnosed with HAC and 59 of these dogs had PDH. The remaining 17 dogs had either an adrenal cortical adenoma or carcinoma or the HAC was unclassified. In addition, and most importantly, one or more noncortisol adrenal steroid hormones were elevated in all but one dog
diagnosed with HAC and 42-50% of dogs suspected of having HAC but ultimately diagnosed with a nonadrenal illness. The question often arises why noncortisol adrenal steroids are commonly elevated in dogs with HAC and nonadrenal illness. The rate-limiting step in the
synthesis of cortisol and the major site of action of ACTH is the conversion of cholesterol to pregnenolone. It is therefore not surprising that any disease causing increased concentration of
ACTH results in increased concentration of cortisol precursors as well as cortisol itself, and other noncortisol steroid hormones.

Summary impact point: Noncortisol steroid hormones are commonly elevated in dogs with classic HAC and nonadrenal illness and therefore, elevated levels are not specific for ACD.


http://sewvma.org/files/march_2015_meeting/atypical_cushings.pdf

[ascamhi]

We just got the blood panel for the adrenal mass back from U. of Tennessee. Not good news.

Cortisol post ACTH: 25.7 Range: 6.5-17.5
Androstenedione post ACTH: >10 Range: .27-3.97
Androstenedione: 1.01 Range: .05-.57
Progesterone post ACTH: 2.23 Range: .2-1.50
17 OH Progesterone post ACTH: 6.08 Range: .4-1.62

Any thoughts?

Ashley

[Harley PoMMom]

Was an Estradiol level listed?

[ascamhi]

Yes normal. Right in the middle of both ranges.

Ashley

[molly muffin]

Okay so it looks like the adrenal mass is a cortisol secreting mass then, since the cortisol is high and there are some other sex hormones values high too.

Have they suggested further steps? At 12 years old I don't know if they would suggest surgery to remove the mass or not. Surgery of course comes with it's own risks.

Does your vet have any experience with adrenal masses and cushings medications?

It's tricky with the kidney failure issues as the manufacturer of vetroyl for instance doesn't recommend treating with vetroyl if there are kidney issues if I remember correctly.

Since the kidneys do seem to be improving I might be inclined to keep an eye on those values and see if they continue to improve and have those discussions about what they would recommend.

[ascamhi]

They are suggesting surgery. She recently had a CT done and the mass does not seem to have invaded any vessels nor are there any blood clots. The medicinal options don't seem to be great and they won't shrink the size of the mass which is pretty large.

[molly muffin]

If you look back to the beginning of your thread here, you can use and print out the guidelines we use for surgery consideration.
What about the kidneys with surgery? is there anything that would increase the surgery risk?

Are you going to have a consult with a surgeon?

[ascamhi]

We had a consult with the surgeon after we got the CT results. There is always a chance her kidneys will be impacted. Given the size of the mass and that it hasn't invaded any vessels we have decided to go ahead with the surgery on the 19th. There will be a criticalist there in addition to the surgeon and an anesthesiologist. So we are doing everything we can to minimize risks. She has started to have panting spells so I'm assuming the hormones from the mass are impacting her. We'll see how it goes!

[DoxieMama]

Ashley,

I will be keeping you and Cloey in my thoughts. Please keep us updated on how she's doing!

Shana

[Harley PoMMom]

I'll be keeping you both in my thoughts and prayers, sending tons of positive energy your way as well. Please do keep us updated.

Hugs, Lori

[molly muffin]

We will be right here sending out positive thoughts. Fingers, toes, paws crossed for a successful surgery and healing.

[DoxieMama]

I'll check in later today to see how Cloey is doing. Positive Thoughts!!

[Squirt's Mom]

Hoping all goes well for your sweet baby! We are right by your side!
Hugs,
Leslie and the gang

[molly muffin]

fingers and toes crossed here!

[judymaggie]

Adding my prayers to others that Cloey's surgery and recovery go smoothly!

[ascamhi]

Hi guys Cloey had her surgery yesterday. They removed nearly a 6cm adrenal mass with zero complications. A big part of that was that we had a surgeon, 2 vet techs, an anaesthesiologist, and a criticalist. The mass had not invaded any veins.

We saw her last night and she looked pretty good other than being drugged up. They did not put her on anti-coagulants because those come with risks as well. She made it overnight - no blood clots, no fluctuating blood pressure.

We saw her this morning and walked her a bit around the vet and outside. Her blood work still looks great, her kidney values are normal, and so we are getting to bring her home tonight!!!!

I cannot believe that after everything I read she is doing so well. They have her on oral pain meds and prednisone. Even though she isn't eating yet they thought she would be better at home.

Thank you all so much for your well wishes. I am still in total shock and I hope that she continues to make a full recovery.

Hugs!!

Ashley

[Harley PoMMom]

Oh Ashley! I am so happy to hear that Cloey's surgery went without complications and that she is doing so well....YAAAAA!!!!

FIngers crossed for an uneventful recovery, please do keep us posted.

Hugs, Lori

[Squirt's Mom]

GREAT news, Ashley!! :cool::cool::cool::cool: I am so glad to hear this and know you are ecstatic! The vets may well be correct - your baby may eat better at home where she is most comfortable. We are here if you need to talk or ask any thing.

YAY Cloey!!!!

[Joan2517]

Great news! You must be so relieved~

[ascamhi]

Thank you!! She did eat last night when we got home. Had a few rough moments but I think it is just pain management at this point. She gets her staples out in two weeks so hopefully it will be an uneventful recovery. I will keep you posted!!

Ashley

[DoxieMama]

Woo hoo! Way to go, Cloey!

[molly muffin]

Just checking in to see if everything is still going well with her recovery. Let us know when you can.