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Thread: Skippy has passed; 12 y/o Yorkie with likely pituitary tumor (Trilostane)

  1. #1
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    Unhappy Skippy has passed; 12 y/o Yorkie with likely pituitary tumor (Trilostane)

    Hello to all and thank you for this forum; I am exceedingly grateful for your knowledge and counsel on behalf of those of us who are struggling to understand this devastating disease. My dog Skippy, a nearly twelve year old Yorkie, has been diagnosed with Cushings. He is symptomatic, i.e., PU/PD, aggressive eating, significant lethargy, the classic pot belly and some weakness in his rear legs. Skippy's blood chemistry is "normal", and an ultra sound of his adrenals revealed one adrenal is enlarged with an adrenal tumor and the other is "slightly smaller". The ACTH failed to confirm whether the Cushings is pituitary or adrenal related. I believe his numbers were 4.6,5.4 at 4 hours and 3.6 at 8 hours. My vet has ruled out diabetes and renal failure. While I have read an exhausting number of articles, I am uncertain as to what I should do next and still don't know what I don't know. My options appear to be to start him on Vectoryl/Trilostane to see if the drug "works" or take him to Purdue University for a second workup and MRI? (The initial cost is estimated at approximately $1,500). (Purdue is a vet teaching hospital but they do not specialize in endocrinology as far as I can determine.) I don't know if he is a candidate for surgical removal of the adrenal gland and/or if I would subject him to surgery despite the cost.

    I would appreciate any feedback that you all can offer. Should I ask the vet to perform the LDDST? I don't believe he has hypertension or proteinuria, but I will double check.

    Thank you for any advice that you might offer.

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    Hello Carole, and welcome to you and Skippy. As you'll see, I'be moved your reply so as to create a thread that is your very own. This way, it will be easier for our members to reply to you directly.

    First of all, it appears that Skippy's diagnostic blood test was actually the LDDS and not an ACTH. The LDDS involves a baseline blood draw and then subsequent draws at the 4 and 8-hour marks. The results you report for Skippy are consistent with both the LDDS protocol and also with a dog who suffers from an adrenal tumor as indicated by the ultrasound imaging. So it would seem to me as though you do have the diagnosis in place, unless your vet is somehow questioning the accuracy of the ultrasound.

    It is rare, but possible, for a dog to suffer from both a pituitary and adrenal tumor. When you speak about the $1500 estimate for an MRI, is that referring to imaging of the head to establish whether or not there is also a pituitary tumor? Or are you seeking more detailed imaging of the adrenals? I would not think that additional abdominal imaging would be that expensive, and in honesty, I believe I'd choose to invest my money in additional adrenal diagnostics since a tumor is known to be there. Depending upon the clarity of the initial imaging, you may want to seek another view along with the advice of a board-certified surgeon. Adrenal surgery is always a very serious undertaking, but the exact size and location of the tumor can greatly affect the risks and time frame for intervention.

    There's much more we can talk about, but I'll quit for now and await your reply. Once again, welcome!

    Marianne

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    Marianne, thanks for your quick reply. My vet is scheduled to call me at noon today. I will seek answers to the issues you raised and clarify the testing issues. I presume that if he had the LDDST as you stated, there is no reason to perform the cortisol test. I will reply with additional info about the proposed MRI shortly. Also, Skippy, a Yorkie mix is 12 not 15.
    Thank you again for your help.

    Carole

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    Whoops, so sorry about prematurely aging Skippy!! I've now edited his age so it should be correct.

    And yes, given a "positive" result on an LDDS in conjunction with an adrenal tumor viewed on ultrasound, I don't think I'd spring for an ACTH right now unless it was desired in order to provide a baseline cortisol reading prior to beginning Cushing's medication. In terms of diagnostics, the ACTH often provides a "false negative" result when adrenal tumors are involved. In other words, the ACTH will fall within normal range even though an adrenal tumor may be causing hormonal abnormalities. So the LDDS is actually the better diagnostic blood test when an adrenal tumor is suspected. However, regardless of tumor type (pituitary or adrenal), the ACTH is the blood test that is used for subsequent monitoring of medication's effect on lowering cortisol levels. So for that reason, some vets prefer to document a baseline ACTH level before treatment begins, in addition to the LDDS.

    Marianne

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    Thanks again Marianne for your reply. I spoke with Skippy's vet yesterday and ultimately I decided to proceed with an MRI of Skippy's adrenals before trying medication. The vet thinks Skippy is in excellent health and that he is very "early" onset Cushings. His enlarged adrenal is.9.7 centimeters; the other plump adrenal is .7 (If I recorded her statement correctly.) She said the tumor has not invaded Skippy's vessels and the tumor itself may be hyperplastic. She believes that further imaging of the adrenals will clarify treatment options so off to Purdue he goes as soon as I can secure an appointment.

    If they recommend surgery and pursue that course of action, would it mean that Skippy will be on cortisone for the remainder of his life?

    Skippy does not appear to be in pain; he is more like a chubby lump, very lethargic and disinterested in life beyond drinking, eating and peeing. The change is shocking as previously he was hyperactive, constantly playing and wanted to be outside every hour of the day.

    I will update this post when I learn more. Thank you.

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    Skippy is scheduled for a consultation next Monday. I will post again when I know something more.

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    Carole, I'm hoping you'll gain some really valuable information from the consultation. One of our members has compiled a very helpful list of questions to ask when considering adrenal surgery -- I can't seem to find it right now , so I'm hoping one of other staffers will add it here for you, or else I will hunt again a little later on. Either way, we'll make sure you see the list before Monday.

    Also, most dogs do not need steroid supplementation long-term after successful adrenal surgery. The remaining adrenal gland typically ends up being capable of producing sufficient hormonal reserves all on its own.

    Marianne

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    I searched under "adrenal tumor" and found the article you referenced. It is indeed very helpful. Thank you and I will post the link when I have a second.

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    Hi Carole and welcome to you and Skippy.

    I believe this is the list of questions that Marianne was referring to and you probably found. I'll post it here so it is easy for you or someone else to find

    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.
    I think you'll know more after the consult at Purdue. Surgery is always a risk, so any information is always helpful in making a decision on what step to take.

    As Marianne stated quite often after having an adrenal gland removed, the other one kicks in and no further medication is needed long term.
    Sharlene and the late great diva - Molly muffin (always missed and never forgotten)

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    Default Re: Skippy, 12 y/o Yorkie with adrenal tumor

    I am posting a follow-up to my earlier posts with the hope that some may find it helpful.

    On 12/4 Skippy had a complete work up at Purdue (excluding neurological). They kept him overnight and did a second ultrasound and an additional test similar to the ACTH stimulation. They did not believe that the adrenal gland was tumorous and diagnosed pituitary cushing's.

    Skippy has been on a regimen of 10 mg Trilostane twice daily since 12/6. On 12/19 they reevaluated and tested ACTH levels. I can't remember the pre test number but the post test was 7. something. (I will secure a copy of his test results and post them.) Purdue sustained the dosage at 10 mg twice daily.

    The vets at Purdue seemed most concerned about clinical symptoms of peeing, drinking and eating. Clearly there has been a significant reduction in the first two. Not so much on the eating front as he had gained a pound between visits. I am concerned that I am seeing very little improvement in other quality of life and physical appearance symptoms. Skippy's belly remains very bloated, skin and fur still thin and his hair is not growing back. He is very lethargic, has muscle weakness in rear legs, a sore on his shoulder and an external tumor on his anus that bleeds and collects feces. (They aspirated the tumor and think it is probably benign; they speculated that it may be caused by Cushing's and will diminish in size with treatment.) Skippy will take short walks and yesterday was willing to play with a toy for a couple of minutes. However, he is now shaking when I put him in the car or try to bathe him. (The shaking first started right before diagnosis and has continued.) His legs shake when he squats to poop.

    So, I am pretty disheartened after 25 days of treatment. Skippy will be retested on 1/23. Purdue did not do an MRI as they felt confident in their diagnosis. I will post his numbers when I secure a copy and provide updates as it seems appropriate. I know that reduction in symptoms takes time but I am so concerned that his quality of life sucks and will not improve.

    But, tomorrow is a new year and hope springs eternal.

    Best,

    Carole
    Last edited by Carole Alexander; 12-31-2016 at 04:55 PM.

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