Adrenal Tumor with huge vena cava invasion!!

[Simba]

Hi All,
Simba's mom here. HELP please. After reading this forum there is such a huge support for Cushing's and adrenal tumors i thought i would at least try to get help understanding what i am up against! Simba is the love of my life literally he is a 13.5 year old lab mix who was just diagnosed with an Adrenal mass and invasion to the vena cava. He had no other signs except i noticed increased thirst which didn't know it was a sign until now. They were checking him for Cushings at least they mentioned this.. This visit was for an ultrasound as a followup to a previous emergent surgery to remove his spleen and hepatocellular carcinoma as noted in his history. Then we rushed over to get a CT scan and see below for the results. They say his vena cava involvement is the biggest they've ever seen?? Is this big to this group? My surgeon doesn't think he would make it through surgery but is willing to if I give the go ahead. Can you guys review and tell me your thoughts? work up other than regular CBC with liver enzymes slightly elevated with protein in urine. BP was 170. I do not know how aggressive i should be and do not understand what i am up against.

History: Previous hepatic lobectomy for hepatocellular carcinoma and splenectomy for
lymphoid follicular hyperplasia. On recheck, ultrasound evaluation identified a right adrenal
mass with invasion into the cranial vena cava.
Description: Within the abdomen, the right adrenal gland is 2.1 cm in size. This mass
extends into the caudal vena cava distending the lumen of the caudal vena cava to 3.5 cm in
diameter. The phrenicoabdominal vein is also distended dorsally. This extension of the
mass in the caudal vena cava extends for a length of 8.8 cm. The left adrenal gland is 1.3
cm thick. The hepatic lymph nodes are mildly larger (0.9 cm). Within the gallbladder, there
is mild soft tissue attenuating sediment. No abnormalities within the liver are seen. The
spleen is not identified. The right kidney is mildly irregular shaped and the left kidney is
unremarkable. In the right prescapular region, there is a 10.3 cm x 5.4 cm, striated, fat
attenuating mass. Multiple lipomas are present within the thoracic and abdominal body wall.
No evidence of lymphomegaly is seen. Within the thorax, no abnormalities are seen. The
pulmonary parenchyma and pulmonary vasculature have a normal appearance. The heart
has normal size and appearance. No thoracic musculoskeletal abnormalities are seen. In
the right caudal gluteal region, there is a 1.2 cm soft tissue nodule just dorsal to the caudal
thigh muscles
Conclusion:
1. Right adrenal mass with invasion into the right phrenicoabdominal vein and caudal vena
cava
2. Mild left adrenomegaly - possible reactive hyperplasia
3. Hepatic lymphomegaly - possible metastatic disease from the previous hepatocellular
carcinoma
4. Presumed liposarcoma, right prescapular region
5. Soft tissue nodule, right caudal thigh - nonspecific
6. Unremarkable thorax

[Squirt's Mom]

Hi Mom, and welcome to you and Simba!

You have given us some great details - thank you! That is always helpful. I have to say after reading your post that Simba is a tough little guy! I can see why you are torn on this decision as a result. We can't tell you what to do but we can share what we know and have experienced to help you form your decision. The first thing I want to do is direct you to a list of questions one of our former members put together based on her experience with several abdominal surgeries for her baby boy, Flynn. Next I am going to give you the link to Flynn's thread so you can read his story. Here is the link to the questions:

http://www.k9cushings.com/forum/showthread.php?8555-Questions-for-dog-owners-considering-adrenalectomy


Here is the link to Flynn's tread:

http://www.k9cushings.com/forum/showthread.php?4242-Flynn-11-y-o-Foxie-Cross-Right-adrenalectomy-Good-Bye-Flynny-We-will-miss-you&highlight=flynn


Whatever you decide, we will stand by you all the way. You and Simba will never be alone. All you need to do is reach out. I'm glad you found us and look forward to learning more about your precious baby boy.

Hugs,
Leslie

[labblab]

Hello, and welcome from me, too! I’m surely sorry, though, for the big challenge that you and Simba are facing. Leslie has given you a great start, and I’ll just try to add a few more thoughts. Surgery to remove adrenal tumors is always a very serious (and unfortunately, very expensive) undertaking. Even under the best circumstances, the surgery involves risks. We have witnessed both wonderful success stories and also heart-breaking losses among our members here. However, the surgery may be viewed as more or less risky depending upon many different variables including age, overall health status, blood vessel involvement, likelihood of cancerous spread, etc.

I am so sorry to say that it sounds as though sweet Simba already has a number of strikes against him. The fact that the adrenal tumor has already invaded both his vena cava and also an additional abdominal vein is not good. The blood vessel involvement makes an already tough surgery even more difficult. There also seems to be suspicion of possible metastatic carryover from the hepatocellular cancer. Also, as a Lab mix, I’m guessing that Simba is a senior gentleman at age 13.5. Just as with humans, any surgery and recovery can be more taxing on the geriatric body, in general.

All of this boils down to saying that, very sadly, Simba is likely not a very good surgical candidate. As the surgeon has told you, there is a good probability that he would not survive the surgery. The really, really hard part for you is that the vena cava involvement is life-threatening, as well. If left alone, presumably the tumor will end up rupturing that essential vein. What a hard and painful decision to have to make. There are so many competing worries and decisions — whether to risk putting Simba through the rigors of surgery, or whether to keep him as comfortable as possible alongside you at home for whatever time he can survive the tumor.

As luck would have it, one of our other members who faced the tough decision of adrenal surgery with her older dog has just now returned to us with an update. You will see that Teddy has had a series of complications, but he is still bravely hanging in there. One difference, however, is that he did not have the involvement with the vena cava. You may want to read through Teddy’s thread, though, because we talked a lot about the pros-and-cons of surgery as Teddy’s mom made her decision.

http://www.k9cushings.com/forum/showthread.php?8918-Adrenal-Tumor-Cushings-struggling-with-decision-treatment

Once again, no matter what you decide, we’re so glad you’ve joined us. I know you have a great deal to think over, so please come back and ask any questions that come to your mind.

Marianne

[Simba]

Simba's mom here. He is my only "child" so this has been so difficult for me to come to terms with - he follows me around, very intuitive and learns new tricks without me even teaching him - just the other day he started opening doors with the door knob?? and he goes everywhere with me. He is my protector, movie watcher, foot warmer, sleep buddy and most of all he is my heart. I do not know how else to describe the love i have for him. I am crying as i write this... Leslie and Marianne i want to thank you so much for the information and referring me to the other blogs i spent much of yesterday and this morning reading and researching what you mentioned. Yes - he is a lab, shephard and rhodesian Ridgeback 80 lb mix pup. Marianne i noticed you are from Georgia - i am in Suwanee, GA. My surgeon is Dr Oshin at North Georgia Vet Specialist. He is amazing and did Simba's other surgery back in April of this year. No one thought he would survive this as it was emergent. This is very difficult since Simba is not showing signs of anything other than drinking water more but i attributed this to the summer heat i guess i was wrong. No change in weight, no losing hair, no change in tolerating activity, very strong, still playing, running, etc. which i do not understand why he has no other signs. Like i mentioned before no lab values.

I understand how much Simba has against him because of the invasive mass into the vessels. As Dr Oshin has told me it is the biggest invasion into the vena cava he has seen and the other docs have seen as well. This scares me as you mentioned it will probably burst and i am trying to come to terms of what i should expect. It is hard for me not to do anything - especially for him. I will speak to my surgeon again tomorrow as he said he would be there for me to answer any questions. I honestly still have hope but not sure if it is just a stage of grief or what. I feel like i am behind the 8 ball with information but this blog has helped tremendously with catching up and knowing others experiences put things in perspective. Thank you again

[Simba]

In re-reading my own post i stated i understand but it is hard to accept and again i just want to thank you guys for putting things in perspective. When someone else puts his CT results into layman's terms it really helps to understand more of the implications of what is going on. Thank you all for the support and if you would like i will post what the surgeons says if anything different to what we know already... i wonder is there anything that could be done medically to support his health - as of right now everyone seems to know more lab values, etc. than i do to even begin to add any supplements, etc. He is currently on I'm Yunnity to support his liver and immunity health from previous issues, Thyroxin 1mg 2 x day, Carprofen 100mg and Tramadol 50 2 x day for arthritis.

Another question maybe you know by experience - time frame we have left?

[labblab]

Gosh, we are nearly neighbors — I’m over in the Alpharetta area! It sounds like you guys are in really great hands at North Georgia Vet Specialists, and I’m so glad your surgeon is being so open and supportive since he’s probably in the best position to answer your specific questions about time frames and possible outcomes. There are several different kinds of adrenal tumors, and each can carry different symptoms and progression profiles. If Simba isn’t exhibiting typical Cushing’s symptoms, then his tumor may not be triggering the release of many, or even any, excessive adrenal hormones. In that case, medication may not be necessary or helpful. Although I notice that his blood pressure is 170, and I’m thinking that is high? There’s a particular type of adrenal tumor that does release a hormone that affects blood pressure, so medication may be warranted for that.

I’m sure you’ll have many questions to talk over tomorrow. In addition, you may just want to ask the surgeon what he would honestly choose to do if Simba were his own dog. Of course, the final decision is yours to make. But that’s a question I always ask my own trusted vet when I’m faced with a hard decision. Sometimes it helps to know what their perspective is, given all the dogs they’ve treated and all the outcomes they’ve witnessed.

And above all, keep on coming back here. Many people don’t understand the depth of the bond that can exist between a human and a dog. But I promise you, we do understand. We totally understand. All of this is so fresh and new to you that you have to be in shock. At least I know I would be. You are doing a wonderful job of advocating for Simba by educating yourself and considering all the options. And at this point, none of us knows how his story will play out. There may still be some unexpected chapters along the way!

Giant hugs flying your way, and do let us know what more you find out tomorrow.
Marianne

[Simba]

Good Morning,

Thank you for being so kind. I have printed off the list of questions Leslie shared and additional questions you mentioned. Waiting for the Vet to call - he tends to call later in the evening when he gets a break. This is really hard since Simba is just as strong and stubborn and everything else like a puppy, he doesn't act like he is struggling in any way. If that were the case i think it might be easier in some respects. I feel like he is a time bomb waiting to go off if he plays too hard. If his BP gets higher, etc. Will let you know what the next step is.

Thank you again

[Squirt's Mom]

We are right by your side even tho you can't see us. Today will be tough no matter what the surgeon says or what you decide; we understand and are holding your hands, lending you our strength. Know you will make the "right" decison because you will base any decision on the love you hold for Simba...and no decision made from a place of love can be wrong.

Hugs,
Leslie

[FoxFire]

It's heartbreaking to hear about Simba's situation. I truly hope that the surgeon will have some hopeful information and answers for you when he calls you this evening.

It is good to hear though that Simba is still his happy and active self and doesn't seem to be in much distress. Sometimes I feel like I've already lost my pup because even as early as last winter he was SO active and energetic, rearing to go, begging me to go out and run around and play, and now he mostly acts like a piece of furniture. :-\ He only recently started on his medication so I'm hoping to get at least some of that energy back in him.

So, if there can be any silver lining to what you are going through with Simba, it seems like he's largely his regular self.

Now, come on medical science... advance faster! I want tiny micro robots that go in and just fix everything!

[Simba]

Hi all,

Thanks for the encouragement. Thanks Kobe for your good thoughts! praying your pup gets better from what i understand and have read it takes time to get all the hormones in check and hopefully your pup will feel better soon. This is a great site to understand everything involved with Cushings and adrenal tumors as it is complex. My surgeon called last night and related still the same sentiment as it would be cutting his life short by doing surgery right now. After understanding more the symptoms i do notice Simba more ravenous - he ate a paper towel the other day...but he has always been a food guy. He is drinking more water but not peeing in the house or begging to get out. He has consulted experts and reviewed all literature around Simba's issue. The issue that is of greatest concern is the tumor in the vena cava. He said it is the size or bigger than his actual kidney. He feels like Simba has developed collateral circulation around the tumor so his blood flow is not impeded right now but obvious risk of rupture if it grows. He has consulted colleagues from UC Davis and in Europe he has worked with and waiting their reply. From what i understand there is an expert he has worked with at UC Davis that is the be all end all with adrenal tumors and has worked with multiple complex surgery cases. I do have Simba's last regular labs which i will post later once i figure out how to attach the pdf. Is that possible? i will also add a picture to show how sweet he is at least to me, :). No test for Cushings yet but maybe someone can help with the rest. Vet says some are elevated but nothing was indicated?

[Harley PoMMom]

If you would type in his test results in a post that would be great, please include the reference ranges and units of measurement. As an example:

ALP 150 U/L (5-55)

Lori

PS..generally if any are abnormal they are usually marked with a H or L.

[Simba]

Hi all,

Good afternoon. I will post what is abnormal. The lab results from 10/1/2018. Is any of this indicative of adrenal issues? This is all i have. Thank you

Potassium 5.5 H normal 4-5.4
NA/K ratio 26 L normal 28-37
ALP 566 H normal 5-160 (ALP on 5/2/2018 was 504)
Platelet 545 H normal 143-448
Lymphocyte 5210 H normal 1060-4950

[labblab]

Hi all,

Good afternoon. I will post what is abnormal. The lab results from 10/1/2018. Is any of this indicative of adrenal issues? This is all i have. Thank you

Potassium 5.5 H normal 4-5.4
NA/K ratio 26 L normal 28-37
ALP 566 H normal 5-160 (ALP on 5/2/2018 was 504)
Platelet 545 H normal 143-448
Lymphocyte 5210 H normal 1060-4950

Hi again! It sounds as though your surgeon is doing a great job of researching Simba’s options. I know it has to be so hard to wait for more info and to consider the alternatives. But it sounds as though he is leaving no stone unturned as far as gathering opinions upon which to base an informed decision.

As far as those lab values, the potassium and sodium/potassium ratio are barely out of range, so I don’t know that they have any significance. Elevated ALP and platelet counts are consistent with Cushing’s, but elevated lymphocytes are not — lymphocytes are often abnormally low. So you have kind of a mixed bag there. At this point, though, it seems as though the surgical issues take front seat over concerns about possible hormonal imbalances. So I’d probably put that on the back burner for the moment since Simba is not exhibiting observable symptoms that seem to be causing him much discomfort.

I’ll keep watching for updates and, yes, please do post a photo of your sweet boy!
Marianne

[Simba]

No new updates yet except i posted a pictureof Simba. My sweet boy ��

[labblab]

Ahhh he’s so handsome!!! Thanks so much for letting us see him. A sweetie, indeed ;-))))))))))

Marianne

[Squirt's Mom]

awwww what an adorable face! He looks like a big ole baby. How sweet!

[Simba]

Thought I would update on Simba. Well he’s still living happy. The only thing I’ve noticed is he seems to be hungry more often but that’s about it. We opted for no surgery since he’s 13 and not showing signs of debilitating issues. Just want to thank everyone for all your advice and help. This site is so helpful. Thank you!!

[Harley PoMMom]

Thanks so much for the update! He sure is a handsome boy!

[Squirt's Mom]

Glad to hear Simba is doing alright!

[Simba]

Thank you! We just appreciate each day with him :)

[NMalfam]

I just read through Simba's thread. I'm so glad to read that he's still a happy boy! I love his face, such a handsome guy!

Nancy

[Simba]

Hi all,

Back again. Well we had an emergency situation last night he almost choked to death on a tiny treat. I performed the Heimlich maneuver on him and stuck my and down his throat. We think he had a seizure during this event since he collapsed and fell over - stiffened but I picked his 85 lb butt up and was not going to let him go out like that! I was literally performing CPR on him till i could pick him up. I just cannot tell you the super human strength it took to get him into a car but i think we do things out of the ordinary for who we love. Found out he had "lar-par" or laryngeal paralysis. Do any of you know if this is associated with anything going on with his adrenal Tumor or exacerbation of it? or have any of you experienced this with your fur babies along with symptoms of cushings? i was so worried and still am about adding any more meds to his regemin that will increase his blood pressure or add undue stress to him. He is currently asleep on his king size bed but I am watching him like a hawk. MD suggested chlortrameton and if he starts coughing robitussin dm which he hasnt been. Maybe only sneezing which i chalked up to bad pollen - live in Georgia and right now it is horrible. Hope all of your fur babies are doing ok & thank for any experience you've had with this

[Simba]

Ah thank you! he is a love bug for sure!

[Squirt's Mom]

How scary! :eek: I'm so glad you were there and able to help him til you could get him to his vet!

LP is apparently associated with Cushing's and other endocrine conditions but I don't know that dogs with adrenal based are more prone than those with pituitary based Cushing's. We have had several dogs here with that condition. You can use the "search" feature in the upper RH corner of the page and search for laryngeal paralysis; it should bring up threads where this condition was at least mentioned. Here are some good links on the condition for you to read as well:


https://vcahospitals.com/know-your-pet/laryngeal-paralysis-in-dogs

https://www.acvs.org/small-animal/laryngeal-paralysis

http://www.acvim.org/Portals/0/PDF/Animal%20Owner%20Fact%20Sheets/Neurology/Laryngeal%20Paralysis.pdf

https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4952489

[Katy1]

Wow!

This is really scary stuff. I have noticed a real change in Annie's bark lately, and so has Jerry. She's not coughing or anything like that, but my first question was, "does Lysodren produce a hoarse, raspy voice/bark?" Fortunately, she has swallowed her pill inside a small ball of food, so I haven't had to force anything down her throat. Now I'm beginning to wonder is "Knowledge really Power?" or perhaps paranoia and also if "A little knowledge is a dangerous thing". Blessings, Karen

[Joan2517]

Huh...Lena's bark changed and she did have a choking episode once. She was eating a piece of apple and the next thing I saw, she was lying on her side, peeing and unresponsive. I picked her up and draped her over my arm and opened her mouth and removed the slice. I thought I was going to have a stroke right there! I put her down and she walked away like nothing had happened.

I wonder is she had LP....

[Katy1]

This has me in “twitcher” mode so I called doc’s office and made an appointment for Annie on Friday. He has the equipment so he can do an endoscopy of her trachea and laryngeal process if necessary. I wouldn’t be so concerned because of her dental last week, but we noticed this maybe even before she started on the Lysodren. Many thanks to whoever posted the vet-info links; read them all. I will attribute this to a ‘senior moment’.

On a more positive note, she made it through her groom and looks great. Her coat is still nice and thick and shiny. No scaling on her back. I really need to learn how to get an album going for her. She has natural schnauzer ears, but right after a groom, they tend to stick straight up like a donkey. Either that, or one ear flops kind of down and the other is up. It just makes me smile. As her coat grows out, her ears get heavy fast and drop into position. Many thoughts, smiles and Blessings to you all and your pups. Karen

[Katy1]

OMG Joan, I would have had a heart attack on the spot. We see doc tomorrow, but now I’m wondering if this maybe a “dry mouth” thing going on because, as I understand-or mis-understand, Cushings seems to be also a chronic inflammatory process. Hence. also the dry nose. Blessings. Karen


T

[Joan2517]

I almost did, trust me....but I just attributed to her extreme hunger. I thought she grabbed it and swallowed before chewing. She did used to sweep in and grab whatever fell on the floor before we even knew it had landed. I did used to call her my little Miss Piggy. It only happened that one time, but I was also always careful after that with the pieces of anything I gave her.

[molly muffin]

We had that laryngeal paralysis once with our molly. We were on a walk, she had a collar on and we'd stopped and talking to some friends, molly was waiting but she would pull sometimes, like let get going and then she just fell over. Nothing in her mouth but she went limp completely. I picked her up and ran home with her, we were only a couple houses away at that point. She was breathing but totally out of it, not responsive, peeing herself. We called emergency, jumped in the car and went. By the time we arrived she was just fine and acted like nothing happened. The vet theorized that perhpas she has placed pressure on a nerve that runs down the side of the neck and can cause the paralysis. Just a theory as they couldn't find anything wrong. I switched her to a harness and it never happened again that god, but I would have just had a heart attack if I'd had to do cpr too.
The was before the cushing diagnosis I think. It's hard to remember sometimes what happened when but think this was prior.