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Thread: Kashmir - Cushpup with possible macro adenoma (Kashmir is now free)

  1. #1
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    Default Kashmir - Cushpup with possible macro adenoma (Kashmir is now free)

    Hello everyone, I'm new here and hoping to benefit from the support and the wealth of collected knowledge I'm finding on this forum. My dog Kashmir is an approximately 12 year old Chow/Heinz 57 mix who was diagnosed with Cushing's in 2017. He was started on Vetoryl and over the next ~18 months the dose was continually reduced based on his ACTH-stim results to avoid over-suppression. He did end up having 2 Addisonian episodes anyway; not full-on crises but stopped eating his food and lost weight (he had extra to lose at this point), yet bounced back quickly with a round of prednisone. After the second episode last fall, he was taken off Vetoryl completely and his February stim test showed him within normal ranges. Even with the constant testing and subsequent adjustments, Kash did well on the Vetoryl and things were good through December 2018.

    Early this year Kash seemed to start losing his spark, was more lethargic, slept more, and wagged his tail less and kept it down instead of curled over his back. He also started panting more again and his belly was more distended, and he got tired quickly on our walks. Around mid-April his appetite started to dwindle and has steadily gotten worse, although I keep enticing him with new things and so far I'm able to keep him eating.

    In April we went to his regular vet for his annual checkup; blood tests showed a low thyroid but everything else looked good. So he started on 0.4 mg of Levothyroxene twice per day. It seemed to help energize him a little at first but he quickly plateaued and regressed. He has also started drinking more water again although not to the degree he did prior to the Vetoryl. Most of the time he just seems zoned out and blah. He sleeps a lot, can be a bit wobbly, has a little trouble navigating stairs, an occasional stumble here and there...

    Because of my gut concern that something was/is wrong, we saw the IMS last week and he ordered a full CBC, thyroid panel, abdominal ultrasound and chest x-rays. Everything looked pretty good other than his Levothyroxine was lowered to 0.4 mg/day. The IMS brought up the possibility of macroadenoma or canine cognitive dysfunction since the tests ruled out other problems. I found this website over the weekend and after reading the macro thread and several dogs' individual stories I am convinced Kash has a macro, even though the IMS tells me I shouldn't jump to conclusions.

    We have a consultation with the neuro vet on Monday June 10 where I will learn more about MRI diagnosis, radiation, other treatment options (are there any? steroids perhaps?), cost, prognosis, etc. If anyone has information I should be equipped with when I go in, or knows of questions I should be asking, I'd sure appreciate you sharing those with me. I also learned today that the clinic has a newer generation unit that can perform "stereotactic radiosurgery", that can generally accomplish in 3 treatments what traditionally would require 15-18 treatments. Does anyone have experience with stereotactic radiosurgery? Are the outcomes better, even if the tumor is large in size or in comparison to brain size? To be clear I have not made any decisions yet and if anything I'm leaning towards not putting Kashmir through RT as he has come to dread vet appointments; between Cushing's and rehab for a separate issue, there have been many.

    The IMS's remarks are pasted below. I will just add that although the vet describes Kash as "medically stable", that does not mean he is thriving.

    Thank you in advance, everyone, for your thoughts and guidance.

    "Kashmir's abdominal ultrasound showed mostly changes suggestive of slowly progressive, degenerative processes
    as opposed to an obvious new and active process to explain the recent concerns. His thoracic X-rays were essentially
    normal.

    On labwork, Kashmir has the typical elevations in liver enzymes we've seen previously, but no signs of dysfunction,
    and the rest of his organ systems are working fine. His urine analysis was unremarkable. His T4 (thyroid hormone
    level) came back slightly higher than the high end of the target range for dogs on supplementation, so we could
    consider dropping the dose some (or just going to once daily at the 0.4mg dose). With that said, the typical symptoms
    of excessive thyroid hormone supplementation are generally what you would expect from giving too much of a
    stimulant - hyperactive, agitation, increased appetite, potentially weight loss due to increased metabolic rate,
    irritability/aggression, etc. None of the concerns we discussed sound like thyroid excess to me at all.

    Based on the fairly thorough information we currently possess, the scenarios that we should be considering most
    closely would be age-related change (such as canine cognitive dysfunction, CCD, which is somewhat similar to
    Alzheimer's disease in people), or a pituitary macroadenoma. To differentiate between these we would likely need an
    MRI performed through our Neurology department. If you do not want to pursue this information, we could consider
    some of the supplemental/nutritional approaches that are used for CCD.

    Based on how medically stable Kashmir appears to be otherwise, I do not think you need to rush a decision about
    how to proceed, but let me know how I can help."
    Last edited by Lori C; 06-05-2019 at 11:08 AM. Reason: Length and clarity

  2. #2
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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Hello Lori, and welcome to you and Kashmir! Thanks so much for all this detailed information, and I’ll definitely return later today to comment further. However, I want to first take the time to really consider all the info you’ve given us.

    In the meantime, though, we’re so glad you’ve found us, and we’ll do our best to help in any way we can.

    Marianne

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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Thank you for your reply, Marianne.

    I feel like we are in a holding pattern until Monday. I've read through the adenoma thread and after searching on stereotactic radiosurgery I found and read several threads including Jed's, Beatrice's and Attila's, as well as others that didn't go the RT route like Pansy and your Barkis. While the threads haven't made me feel very hopeful about Kashmir's long-term future, it's been amazing and heartwarming to see the lengths that so many pet parents have gone through for the love of their dogs, and the guidance and unwavering support offered by forum regulars and members.

    I'm trying to spend extra time with Kash, trying out different things to keep him eating, doing research to educate myself, worrying and crying, and then telling myself not to spoil my time with him by worrying and crying. This morning Kash seemed slightly more alert and actually wagged his tail a little. It was a short, sweet surprise, and I wish it would have lasted longer than a few moments, but I'll take it anyway and be grateful for it.

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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Hi and welcome to you and Kashmir!

    My Squirt developed doggy dementia. At first she just slowly withdrew, sleeping more and more then she started doing more obvious things like going to the wrong side of the door to go out or come in, getting stuck behind or between furniture, turning in circles for much longer than she used to when laying down like she was stuck in that gear of going 'round and 'round. Then she started pacing in the late afternoons, similar to sun-downers in humans with Altzheimer's, that went on most of the nite. She would walk the same route repeatedly over and over and over until I was sure she would fall over from exhaustion but she never did. My little Fox also developed dementia and exhibited the same signs. In time both of them stopped eating and drinking on their own and Fox lost complete control of her bladder and bowels. Those were their messages to me that they had had enough - when they could no longer eat, drink, or manage voiding normally.

    She took a stable SAMe product that is no longer available and it helped her a great deal. Anipryl was also tried but it had little effect on her but has worked for other dogs who had the same problem. There are a variety of other supplements touted online as helping with doggy dementia but I have no first hand knowledge to share with you about them.

    I hope you find the answer for your sweet baby boy soon and a viable treatment that brings you both some relief soon.
    Hugs
    Lesile
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Hi Leslie! Thank you for sharing what you experienced with Squirt and Fox. There is definitely a lot of symptom overlap between CCD and macro adenoma. Were either of them Cushing's dogs and if so, did you have a CT or MRI and that's how you knew they had CCD and not a macro?

  6. #6
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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Squirt was a cush pup, Fox was not. I did not have any testing done on either of them other than maybe an xay on Squirt, I can't remember. I felt I had learned enough thru the cush journey to be able to tell if it was a macro vs dementia as time passed and I wasn't going to take any action if it was a tumor for either regardless so the testing for a tumor would have simply been for info only; that expense could be better put to other uses in my case. Neither developed head pressing which is one of the first signs I saw in a Boston I had who had breast cancer that spread to her brain and is also one of the hallmark signs of any brain tumor in dogs. Neither had signs of failure to thrive (for lack of a better phrase) as time went on until they stopped eating. Until then they enjoyed their food and treats. They were both very confused and withdrawn most of the time but would have moments when they seemed to be present - Squirt more than Fox; both had the pacing, both lost bladder control but only Fox lost bowel control....and that was the extent until their appetites failed. Fox's loss of bowel control happened shortly before her appetite failed.
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

  7. #7
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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Thanks, Leslie, for your response.

    I took Kash to the dog park on Thursday afternoon; he didn't have energy to walk far so we just stayed near the entrance where he enjoyed saying hello to some of the other dogs. He has become much more dog-friendly over the last couple months; when we're walking and we see another dog it really grabs his attention and he likes to go say hi. He was not always like this, but it is sweet to watch. Friday evening we took a half hour walk; we don't go far because he needs to take it very slow, but it was nice and it was a beautiful day weather wise. He had a little stumble where he missed the second step getting down from my bed, but fortunately he was okay and it hasn't stopped him from successfully using the steps since then. I had to fill out some paperwork for the neurologist appointment and they wanted a list of what I feed him, which is not the easiest question to answer since I'm trying all kinds of different dog and human things to keep his interest. He ate reasonably well this weekend in terms of quantity. Perhaps not quality, but I'm just happy he's eating. It's been a good weekend with him being slightly more alert and wagging his tail and me getting him to eat, so I'm not looking forward to the appointment tomorrow which is going to make his illness feel real again.

  8. #8
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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Hi again, Lori! I'm sorry it's taken me so long to get back to you, especially since I didn't make it back before your appointment today. But the positive part is that now you'll be armed with some more information when we do talk again.

    Since you've read our "Macroadenoma" thread, you'll know that I lost my own Cushpup, Barkis, to what we suspect was an enlarging pituitary tumor. So my heart definitely goes out to you as you try to sort out an accurate diagnosis, as well as the best path forward. In answer to one of your questions, we've had dogs here who were treated by conventional multi-part radiation treatment, as well as some who've had much briefer stereotactic procedures. Some dogs have done well with either type of treatment; some not as well. But we'll be happy to talk about that in more detail if it seems warranted. Right now, we'll just be anxious to hear what the neurologist has to say.

    So I'll hold off on writing more until we do actually know more. But once again, I'm so glad you've found us, and we'll be watching for your update re: today’s appointment.

    Marianne

  9. #9
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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Hi Marianne,

    Thanks for your kind words. Yes, I definitely am familiar with Barkis and am so glad to have your guidance through this. Is your avatar picture of Barkis?

    We saw the neurologist today and she confirmed Kash's symptoms are neurological. Given his Cushing's history, the most likely scenario is his pituitary tumor has grown. Without an MRI she of course cannot rule out that it's some other kind of brain tumor, or even that it could be both the pituitary and another one causing his symptoms (she was just giving me all the possible scenarios). She thinks its unlikely that it's infection or inflammation that is causing them though.

    She recommended starting on prednisone to see if it improves his quality of life. He is on 10 mg per day twice a day for 3 days and we are going to see how he responds and then adjust/taper. I gave him his first dose around noon and decided to go to work for a couple of hours since he was worn out from our visit anyway and wanted to sleep. When I got home he wasn't at the door which was really unusual, but I found him on the bed and he walked down the bed stairs more quickly than normal which surprised me; we went for a walk and for the first couple minutes he was holding his tail up and trotting a little. I was thinking 'wow, the prednisone kicked in quickly' but after that little burst of energy he kind of slowed back down. So I don't know if that short spike was related to prednisone or not but it was nice to see. Anyway, since it wasn't overly warm today stayed out for about 45 minutes; we go super slow and stop a lot but that's okay - I cherish every minute with him. We visited some kids and said hi to their dog. Kash is such a cute teddy bear kids just love him and want to pet him.

    The vet said that if Kash responds well to prednisone it's an indication that the tumor might also respond well to radiation. I'm not convinced I want to go that route but I figure we'll just see what the next few days hold, plus she is going to email me with some studies on stereotactic surgery and outcomes, and outline all the options and information she gave me today since it was a lot of information. I should have the email tomorrow so I will post an update here with that information. I'm happy to say I really liked the neurologist; she was knowledgeable, empathetic, very forthcoming with information, and answered all of my questions without making me feel the least bit rushed. After reading some of the other threads on here I feel so fortunate to have a veterinary specialty clinic 20-25 minutes from my house.

  10. #10
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    Default Re: Kashmir - Cushpup with possible macro adenoma

    Lori, thanks so much for your quick update. I surely do hope that you’ll see continued improvement with the prednisone, regardless of whether or not you decide to proceed with invasive treatment. As I mentioned above, we’ve had dogs here who have been treated for their macrotumors using differing modalities and the results have been variable across the board. Some have done well and enjoyed improvement in their quality of life for multiple months; others have not seen a great deal of improvement or suffered from various complications associated with the procedure. For this reason, I’m not going to try to identify any specific stories for you to review, since there really is no single outcome that has been “typical” here. Probably the research info that the neurologist will supply to you will carry the most updated prognostic info.

    One point that I assume she’s already mentioned is that the radiation is hoped to resolve or at least improve the neurological symptoms for a period of time. However, the tumors are not removed in their entirety, and eventually regrow for most all dogs. Also, the conventional Cushing’s symptoms are usually not helped by the procedures, so ongoing Cushing’s medication is typically required. I don’t mention this to dissuade you from considering radiation, but just to let you know that, unfortunately, the procedure does not yet offer a complete permanent cure.

    No matter what you decide, I am so touched by your calm acceptance of, and sweet responsiveness to, Kashi’s current situation. Since you read Barkis’ story on the Macroadenoma thread, you’ll know that one of the biggest sorrows and regrets that I still carry with me was my inability to just be “present” with him during our last days together. I was so frantically trying to search for solutions that my focus was on treatments instead of cherishing our time together. So no matter what you end up deciding, I believe you’re offering him the most important and valuable treatment of all — your undivided love.

    And yep, my avatar is indeed Barkis. Every time I see his face on this forum, I feel as though I’m still honoring his sweetness and his bravery. He’s what brought me to this family so many years ago, and he’s the reason why I remain. He will always truly be “my bestest boy.”

    Please do continue to update us as often as you can. And please give sweet Kashi a big hug for us, OK?

    Marianne

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