Looking for advice on Adrenal Gland/Vena Cava Tumor

[LilyLoo]

Hello,
I am looking for advice for my dog Lily. She is ~ 6-8 years old, 50-lb lab mix rescue dog. I'll start by saying she does not have Cushing's disease - but this forum came up as I've been searching for any and all info related to adrenal tumors. Here is the situation:

- Over a 1.5 month period, Lily's ALT levels have gone from 315 to 380 to 415 (roughly). Originally discovered during annual check-up (no symptoms and she was otherwise healthy)
- Ultrasound to troubleshoot the liver actually found a tumor on her adrenal gland, and it showed that it had invaded the caudal vena cava
- Type of adrenal tumor is not definitively known at this time, but Lily is not showing ANY symptoms (eating normally, bowels normal, and normal energy). We confirmed her lungs and heart are clear.
- To remove the tumor, we understand it's a risky surgery, with a morality rate somewhere around 20%
- Surgeon's main concern/urgency was around the possibility for the thrombus in the vena cava to become dislodged and travel directly into the lungs/brain and create an acute condition that would lead to death
- Internal medicine doctor felt surgery was too risky. She did not have the same concern about the vena cava thrombus, and felt that Lily would have a good survival rate with just monitoring her condition. She offered that chemo could be done to help slow the progression of the tumor
- So we have to make the decision to operate and remove the adrenal gland/tumor in the vena cava, and then it's an additional issue of still working on her original liver problem (IE doing a biopsy on the liver)

We welcome ANY feedback/opinions that the members of this forum would have. Our main questions to start:
- For dogs with similar conditions (adrenal gland tumor + vena cava thrombus), have you seen a similar mortality rate, or would you argue that her chances would be different? (considering intraoperative and post-op deaths)
- Any experience with not doing surgery in this situation, and just pursuing palliative care (w/ or w/o chemo), and what did survival times look like? We know that is really hard to estimate.

We're really just trying to wrap our heads around the two different options for the tumor, and how the two doctors had such different opinions!

Thank you!!

[DoxieMama]

Welcome to you and Lily - though I'm sorry for the difficult decision you are facing! I don't have anything but an opinion, and I'm not a vet or educated in the field, and if anything I say offends, please... disregard. I sure don't mean it to.

I'm curious as to the doctors' opinions as to Lily's life expectancy with the possible options. An educated guess, if you will.

What symptoms might be expected if a thrombus were to be dislodged? Is there any way to know one exists BEFORE it were dislodged, such that it could be dealt with prior to a crisis situation?

There is also the perspective that a surgeon is more likely to recommend surgery than another doctor... a pessimistic viewpoint, to be sure, that each of them are more interested in their own personal financial gain than that of the patient. We'd hope that not to be the case, but I can't help but consider it myself (I have family who believe this strongly so we are relentless in our pursuit for as much certainty as possible). I do not mean to suggest that your surgeon or IMS don't have Lily's best interest in mind, but is it possible to get a second (third or fourth) opinion from a surgeon and/or IMS that will NOT gain financially from their recommendations? Another educated perspective might be beneficial, even if you have complete trust in your current doctor(s).

Again, I am so sorry your family is going through this. I am glad to know that Lily does not have any symptoms or appear to be suffering from the tumor, and hope she continues to do well. My best to all of you.

Shana

[Joan2517]

Yes, a very tough decision. Shana is right about getting other opinions. My Lena had one, but she had Cushing's and was symptomatic. She was also 14. My vet recommend not putting her through the surgery and I did not pursue it. Even if she were younger, I don't think I would have put her through that.

You have to do what feels right for you and Lily, though. Gather as much knowledge as you can and then make an informed decision. Thankfully she doesn't seem to be suffering at all.

[LilyLoo]

Thank you Shana and Joan!

Surgeon's perspective on life expectancy:
- With surgery, she could live out her normal life span, or it's possible that in 1-2 years the cancer could come back (same location or new location)
- Without surgery, he thinks she could go on the order of months, but not on the order of years

IMS perspective:
- Thinks she could live a normal lifespan without any surgery

Part of the problem is that we don't really know how old she is.

We are trying to get more opinions through family/friends that are vets, and we've found a vet who has researched this topic who is providing some input via email. But it might be worth an examination/consultation with a totally unbiased vet. It's understandable that different types of doctors have different functional backgrounds and different schools of thought.

That is a good question about reacting to the thrombus being dislodged. I was imagining that it would be something pretty immediate, but maybe that's not the case.

Thank you for your input!

[molly muffin]

Hello and welcome to the forum.
Well this is a tricky situation with the surgeon recommending one thing and the internal med vet recommending the opposite. So yes, 2nd opinion. Did they do a CT scan or just an ultrasound?
My thoughts are wondering how far into the vena cava it is. It is possible to operate if it is in the vena cava, and most of the ones we know of the surgeons always thought it was imparative to get it out of there, because if it grows, it will grow all the way up into the heart itself, or the thrombosis is likely to detach and if it does it will move up and cause a blockage.
Both of those are very serious and are life taking.

The risk for surgery is more with the vena cava being invaded already than if it hadn't been.

I don't know anything about success rates with chemo as I, off the to of my head, can't think of anyone who has tried it, but one of the other admins might be more aware.

What I do have is a questionaire that one of our members whose dog had a pheo and underwent surgery wrote for us. I'm going to copy/paste it here:

This was put together by one of our members Trish whose dog Flynn under went an adrenalectomy for a pheo successfully.


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.

[Stevie's Mom]

Hello!

I too am in a very similiar boat as yourself and am searching the internet for the best route to take. Except my situation is surgery or ........ I was wondering, if you don't mind my asking, what you decided to do an how Lily is doing now.
Thank you

[lins211]

I saw u just posted. My dog is going in for adrenalectomy tomorrow morning. It has invaded the vena cava. We saw two surgeons and both recommended surgery. Im not sure how chemo would be a good route. If its invaded the vena cava there is a gap to fill. They gave our dogs 4 months to live. I can keep u updated after tomorrow. We need all the paw prayers possible.

[LilyLoo]

Lins211 -- sending prayers your way! Have faith in your doctors and the unbelievable resiliency of your pup!

Stevie's mom - so after my original posts, a LOT has happened. We did more research online, and even contacted an author of a research paper on survival rates for adrenalectomies with pheochromocytoma. He was a god send and actually replied to us - with reassuring information that surgery techniques have improved, and survival rates are much higher than the article he had published. We went to a different vet hospital for a second opinion and met with a great team (University of Pennsylvania Vet Hospital, in case you're in the area). They took a much more detailed approach to explaining Lily's situation, and 100% recommended surgery. We did some blood work (Low Dose Dexamethasone Suppression) and a urine test to try and more definitively diagnose the pheochromocytoma vs an adrenal carcinoma. The tests were not conclusive, but did point more towards the pheo. So we scheduled her for surgery and started her on phenoxybenzamine as a pre-Op treatment.

I'm not trying to scare you, but rather just give all the facts of what we went through so you can be prepared. The surgery did have complications with her blood pressure and she did require transfusions. The tumor had grown significantly since the last ultrasound, and it had attached itself to the wall of the vena cava which made the procedure much more difficult. They had a tough time balancing the thickness of her blood with respect to preventing clots vs excess bleeding. The night after the surgery Lily did collapse and went into shock, but recovered. She stayed in the ICU for quite a few days and required many more blood transfusions. She also wouldn't eat during that time. But the surgical and ICU team at Penn was AMAZING. We can't stress enough the importance of the post-op care for this type of surgery. The team verified that the full tumor was removed, and that it was in a fact a pheo.

The recovery was still slow when we got home. Lily developed pancreatitis while she was in the hospital, so she had a lot of issues with uncontrollable diarrhea. She didn't eat for over a week, except for us forcing a crazy amount of medications down her throat. When she still wasn't eating (and this is a dog that will do ANYTHING for 1 single kibble), we took her back to the vet to see an internal medicine specialist. They did another ultrasound and found that her gall bladder and spleen looked abnormal, but not too concerning to react yet. We were discussing options for a feeding tube with the doctor after the ultrasound, when Lily decided to start eating some kibbles in the waiting room. That was a huge step!

We went back 1 week later for another ultrasound. The condition of the gall bladder and spleen hadn't worsened, but hadn't noticeably improved either. The most conservative recommendation from the doctors was to undergo surgery to remove both of the organs -- apparently dogs can function without them. But at that point, Lily's overall health and behavior had really improved, so we were very hesitant. The doctors felt that if the conditions worsened with either organ, we would know and could react -- and that it wasn't truly necessary to take them out preemptively (we consulted a surgeon too). She felt that the organs got damaged (infarcted) during the various stresses of the surgery and recovery.

So now it's been over 10 months since Lily's surgery, and she is 100% happy and healthy. She had her annual vet checkup a few months ago, and our doctor at Penn didn't feel that any additional diagnostic work was necessary. Her routine blood work came back OK. What caused us finding the tumor in the first place was investigating abnormal liver enzymes from blood work - that ended up being copper hepatopathy. She did a course of medication and is on a prescription no-copper diet, and her subsequent blood work came back ALMOST normal. So we'll take it! What an adventure.

Please let me know if you have other questions or want to talk. I know how hard this can be!

~Emily

[lins211]

Henry made it through surgery!! After an entire day of waiting, the surgeon called and said it went "textbook" and everything went great. I know were not out of ruff waters yet but at least we got through surgery! It was into the vena cava but he said it looked like a little hot dog slither inside of it. I will keep you guys updated! After today I may be the one that has a heart attack!!

[LilyLoo]

That’s wonderful news! You got this Henry!!