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

[Lori C]

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."

[labblab]

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

[Lori C]

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.

[Squirt's Mom]

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

[Lori C]

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?

[Squirt's Mom]

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.