Winston, 8 year old westie with adrenal tumor

[WinstonTheWestie]

Hello all,

I just wanted to take a moment and remark on how wonderful and supportive this community appears to be! My dog has not been diagnosed with Cushing's, but it has been a wealth of experience and information for me to read. I've been pouring over posts for several days now. I hope it is okay to post here even without the Cushing's diagnosis, but I believe some of you have been through a situation similar to what I am now.

My dog is an 8 year old neutered male Westie who was diagnosed with an adrenal nodule/mass about 18 months ago. It was an incidental finding discovered during a routine ultrasound performed while working up chronic vomiting that led to a diagnosis of presumptive IBD (no intestinal biopsies, but he completely stopped vomiting once eating a prescription hydrolyed food). The mass was off his right adrenal and measured approximately 1 cm. His left adrenal was at the small side of normal measuring about 0.45 cm. We did another ultrasound 3 months later, and things were static. Another in 9 months (so a year after initial discovery of the mass), and it was still very similar in size at 1.1-1.2 cm with the L adrenal slightly smaller at closer to 0.4cm, but this was with a new internist due to a move halfway across the country for my job. This new internist recommended continued monitoring every 6 months because things still seemed static.

A couple weeks ago, at our most recent recheck, his right adrenal mass had grown to 2.2 cm! Luckily the internist didn't think the mass invaded his vena cava. It had been a busy little thing in the last 5.5 months. Winston is still symptom free. The internist thought his liver may be very slightly more rounded on ultrasound, so she wanted to do the low dose dex supression. His other significant ultrasound findings were likely secondary to his IBD. Regular bloodwork was completely within normal limits, and his chest x-rays were considered normal overall. His low dose dex was negative, with his cortisol going from 1.3 to 0.3 and 0.4 at 4 and 8 hours, respectively, I think.

Given how fast this mass has started growing in the last few months, the internist recommended an adrenalectomy. We discussed blood testing for pheochromocytoma or continued monitoring as other options. So now I face the decision of whether to pursue this risky surgery in a dog that has no clinical signs. On one hand, he is as healthy now as he will ever be, and there seems to be no signs of tumor invasion as of now. On the other, I'm scared he is going to be one of the 10-20% that die as a result of this procedure.

I am lucky to be on staff in a large veterinary hospital, so I sought second opinions from another internist and a surgeon, both who agreed that they would recommend the adrenalectomy as the ideal choice. I had a focused ultrasound performed by a radiology resident, and he also thought that the tumor did not invade Winston's vena cava (yay!), but he was worried that it was adherent due to something he saw. I called a surgical oncologist at a former hospital I worked at (I had a close, mentor-type relationship with her and she knew my dog well), and she also thought adrenalectomy was the way to go.

So, we are scheduled for adrenalectomy with a surgeon with an interest in surgical oncology/soft tissue on August 9. I do feel fairly comfortable with our surgeon (can you ever feel 100% when it comes to this risky surgery?). She has done quite a few of these procedures successfully, including cavotomy, should that be necessary. The internist also wanted GI biopsies during surgery, but the surgeon has recommended that we skip those (or at the very most just take one biopsy instead of the usual 3-5) because anesthesia time is a negative prognostic thing and she wants Winston off the table as quickly as possible without spending 30 minutes getting biopsies for something that is stable with treatment, which makes me happy that she is looking out for his best interest. The surgeon I know personally remarked that it's often tougher on the anesthetist (who is board certified at this clinic) and internist managing the case intra- and post-operatively and she felt ok about my surgeon choice. Winston was started on phenoxybenzamine this weekend just in case the tumor happens to be a pheochromocytoma. The internist feels that it is probably a benign adrenal cortical adenoma given the slow growth and lack of vascular invasion, but of course the only way to tell is to cut it out for a biopsy.

I just pray he does well and I don't regret my decision to pursue this. Thanks for reading my non-Cushing's novel.

-Winston the Westie's Mom.

[molly muffin]

It sure sounds like you have a good group working for you and Winston. Surgery is always scary as there are no guarantees. The post op period, after surgery is often the riskiest time. You want to make sure there is no clots that can travel after the surgery. Taking BP into consideration is always advisable as either too low or too high and you run into problems.

I will go ahead and copy/paste in our questionaire guidelines for going into the surgery and considering it, just in case it makes you think of something you hadn't before:

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.

That one adrenal gland is so large and the other becoming smaller usually is a sign that it is a functional adrenal tumor. The large one produces the cortisol in excess so the other one stops working. This means that after surgery you are going to want to be on a treatment plan for cortisol stabalization, but not over do it because you want the other adrenal gland to pick up the workload.

Do let us know how things are going up and including the surgery. We'll stand with you side by side, as we all understand the worry and stress associated with sending out furbabies into any kind of scary situation.

[WinstonTheWestie]

Winston had surgery today. His blood pressure before phenoxybenzamine was 190, and first thing this morning it was 105, so that was good. We decided not to do a CT before surgery. They anesthetized him about 11:20 for prep (shaving, arterial catheter placement), and rolled into surgery a little before noon. They called at 12:15 because what we thought was a previous cyst on his pancreas was a little funny looking and they wanted permission to biopsy that. They also took three biopsies of his intestines to definitively diagnose his presumptive IBD. They called at 4 pm to say he was in recovery. The adrenal tumor was "intimately associated" with his vena cava and she had to work hard to get it off, but it did not enter into the vena cava, and there seemed to be no thrombus present either. He did great under anesthesia with no hypertension, hypotension, or arrhythmias. He didn't need a blood or plasma transfusion.

Now, we've gotta avoid those pulmonary thromboemboli and deal with any possible pancreatitis now, but they think he'll be able to come home on Friday. I think they said he's continuing the phenoxybenzamine until we know what type of tumor it is, they started steroids to prevent an Addisonian crisis with his remaining adrenal since it is still possible he had very mild Cushings given the smaller "normal" adrenal, he's on a metaclopramide infusion to promote GI motility after the biopsies, and he's on fentanyl transitioning to tramadol for pain. They're getting him up frequently for walks, and plan to feed him in the middle of the night if he's willing to eat. I get to visit around lunchtime tomorrow. We'll do an ACTH stim in about ten days to assess function of his remaining adrenal. He's still only about halfway out of the woods, but at least he has made it this far!

[molly muffin]

Awesome news. Can't wait to hear that he is fully recovered from his surgery and doing well. Great team you had working for him.

Keep us posted. Sounds like for now, everything is going smoothly and he is right on schedule for recovery.

[Joan2517]

!Oh, that is such good news...I'm so happy for you!

[WinstonTheWestie]

Thank you both for your kind words.

I got to see him yesterday. He was obviously uncomfortable and really quiet, but he seemed as good as can be expected I suppose. The first time I visited about 2pm, they didn't even bring a blanket for him to lie on. He sat against my leg and would try to lie down, then it was like he would stop himself halfway down because it wasn't comfortable from his incision. I only stayed about ten minutes because I had to get back to work. They said he ate that morning, wasn't showing any signs of pancreatitis, and really hates his e-collar.

I was able to talk to his surgeon again briefly at that visit. She said she realized that after surgery she forgot to tell me that she had to increase her incision to get more room during surgery and she even had to open up his little chest and move his diaphragm up a little and resew it higher! Oh my! She said everything went smoothly with that and they got the air out of his chest before they woke him up...I hadn't even realized that was something she might have to do. But I'm glad it went well and I guess by not knowing that was happening I had one less thing to worry about.

My mother and I visited for a little bit late yesterday evening as well. This time I brought a blanket of my own for him to lie down on in the exam room. He seemed a little more comfortable and did lay down and take a little nap while I was there. His biopsies were submitted today, and they think he will be able to come home this evening if everything continues to go well.

[Joan2517]

Wow! It is good that you didn't know...that would've made me more crazy with worry. Give Winston a hug for me. One for you, too~

[labblab]

Thank you so much for this update! I'm sorry I didn't have the chance to welcome both you and Winston earlier, but I've been following your thread and I am so relieved to know the surgery is now behind you! I can surely imagine how worried you have been, and how relieved you'll be once Winston is home with you once again. What a little trooper -- he has certainly been through a lot during these past couple of days.

Anyway, thanks again for letting us know how you guys are doing, and we'll be very anxious to hear more. Keeping all fingers crossed that he'll be back home again this evening!

Marianne

[WinstonTheWestie]

This forum helped me immensely when I was deciding on surgery, what to expect, what questions to ask, etc. I spent many hours searching the forums for 'adrenalectomy', 'surgery', and reading the stories of the beloved pets shared here. I wanted to 'pay it forward' in a way and make sure people know about our experience as well, even if I wasn't actively posting the decision-making process leading up to surgery. There were definitely some nights when I was at peace with the decision and others where I was sobbing, petting him, and begging him not to die. But in the end I was pretty comfortable knowing that I was doing what was recommended by numerous vets and what seemed to be the best thing for him, even though it was scary. I'm just glad it has gone this smoothly so far (knock on wood, of course).

The surgeon just called for this morning and said he is a "rockstar" and is comfortable and eating great (so no pancreatitis!). He has been approved to come home! We're going to get him at 5 pm tonight. Luckily I live in the same town as this hospital, so I can rush him back should his condition change. I live in a second-story apartment, so carrying him up and down the stairs to go do his business while his incision heals more will be an adventure.

[Joan2517]

Great news!