Left Adrenal tumor. Thoughts on how you would proceed from here?

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Left Adrenal tumor. Thoughts on how you would proceed from here?

FS 11 yo Cockapoo

Significant past medical history:

Multi-year history of allergic dermatitis and recurrent seasonal otitis currently on RC PD diet

2014 Cruciate surgery left knee

2015 Probable partial cruciate tear right knee O elected conservative tx. Currently on Gabapentin,Dasaquin and acupuncture at home. Nsaids avoided given variable borderline high SDMA results. BUN, Cr normal.

2/19: O reported exercise intolerance and weight gain. Full blood panel normal with exception of Thyroid and mildly elevated Cholesterol.

Total t4 0.4 (1-4)

FS 11 yo Cockapoo

Significant past medical history:

Multi-year history of allergic dermatitis and recurrent seasonal otitis currently on RC PD diet

2014 Cruciate surgery left knee

2015 Probable partial cruciate tear right knee O elected conservative tx. Currently on Gabapentin,Dasaquin and acupuncture at home. Nsaids avoided given variable borderline high SDMA results. BUN, Cr normal.

2/19: O reported exercise intolerance and weight gain. Full blood panel normal with exception of Thyroid and mildly elevated Cholesterol.

Total t4 0.4 (1-4)

Free T4 (ng/dl) < 0.3 (0.6-3.7)

Free T4 (pmol/L) 3.9 (7.7-47.6)

cTSH 0.43 (0.05-0.42)

Started on Thyoid supplementation at 0.02 mg/kg. O reported significant hyperactivity so halved dosage and recheck of T4 2 weeks later 4-6 hrs post pill 1.6 (1-4). O reports vast improvement in activity levels as well as some loss of weight. Was moderatley overweight.

 O has reported PU/PD and urinary accidents in house off and on over last year. Repeated urinalysis showed great swings in specific gravity from 1.008 to 1.036. Most recently on 3/28/19 morning sp. Gravity 1.030. Multiple urine cultures negative. No proteinuria ever seen.

Recent blood pressure 137 average of 5 Dopler readings.

Repeated cbc/biochem panels over last year have been normal with exception of boderline sdma and Cholesterol which varied between 422 to 519 (131-345 mg/dl). Alk Phos always WNL

 Ultrasound performed yesterday along with ACTH stimulation

ACTH Pre: 6.6 Post 15.1

Other than PU/PD O thinks the dog is doing great!

 

Videos show L adrenal mass and normal R adrenal as well as hyperechoic liver nodule. 

Comments

rlobetti

With that ACTH response would

With that ACTH response would think that you are dealing with a functional adrenal nodule, however, there should be a small contra-lateral adrenal gland with is not the case.  Did color doppler show any possible turbulant flow in the CVC?

Ideal therapy would be CT scan and unilateral adrenolectomy.

EL

Nice imaging Marty!.

Nice imaging Marty!. regardless of anythign I would get it out as the sonographic echotexture and multifocal irregular expansive contour suggest neoplasia either carcinoma or pheo. Can run a urine catecholamines (Marshfield labs) to rule out pheo though the BP looks ok they can spike and drop Bp at any time. Likely carconoma and not invading so I wouldnt give it a chance to do so. Can run full adrenal panel at u tenn to assess other endocrinopathies that may be associated.

Marty22

I didn’t see any turbulant

I didn’t see any turbulant flow in the CVC but was concerned about possible aortic invasion in the first video posted. Is that just overlapping structures I’m seeing ? 

Marty22

I added a colorflow video of

I added a colorflow video of the mass for what it’s worth. Having some difficuties with uploading to the forum, hopefully it will show up. 

EL

One a thread is started you

One a thread is started you can only post stills… its a limitation of the system unfortunately and means an entire forum rebuild ( :()… don’t get me started … but you can start another thread with video and paster the URL to this thread.

Regardless, that expasnion on the LAD may be expansion into the phrenic vein btu most surgeons that do adrenal surgery can remove a mildly invasive adrenal mass like pulling our a mushroom.

EL

Is vary rare that you have

Is vary rare that you have aortic invasion by adrenal tumors as the aortic wall its thick and pressures much higher. Adrenal tumors like the easy pathway slow flow easy slide into the cvc through the phrenic vein.

 

Marty22

Thanks!!

Thanks!!

Marty22

Just a follow up report.

Just a follow up report. “Muffin” is going to AMC in NYC for CT scan and probable surgery. I’ll keep you posted. 

EL

Cool let us know the results.

Cool let us know the results.

bhylands77

I am willing to bet that this

I am willing to bet that this will be a pheo due to the emrgence of the mass from the medulla as seen on the third video. There is preserverance of the cortical layering in the non affected part of the adrenal gland. There is no suppression of layering in the oposite gland clearly suggesting that it is not secreting cortisol.

The shape is much more along that of a pheo. Carcinomas by the size are much more irregular in outline or contour. There is clear flow in the phrenicoabdominal vein so there will not be any CVC invasion. Not sure what more a CT is going to tell you. Let us know what is finally found.

Marty22

Well……
AMC performed a

Well……

AMC performed a low dose dex suppression test, Urine catecholamines and a CAT scan. Their conclusion was that: 

Not consistent with a Pheo

Suggestive but not definitive for Cushing’s. Rec an adrenal panel (Unniversity of Tenn) for conformation if wanted. 

CAT scan showed no evidence of invasion.

Still recommended surgery but O is hesitant and has decided to monitor over time given that the symtoms are not that bad at this point. 

EL

bob on the CT question I sued

bob on the CT question I sued to not do them… until i got one:) and of course depends on technique and resolution but also its a bit of semantics because surgeons that cut adrenals, at least in my neck of the woods, prefer to have CT for sx planning of adrenal masses. Invasion of the CVC and superimposition of the mass upon the CVC and phrenic can look similarly if you dont get the exact angle and doppler position and setting. Moreover, hi res CT with contrast can help pick up subtle mets in the liver or chest that US wont (color mapping and contrast studies on US help) and since CT is gold standard for chest mets over rads and ideally CT the chest first why not sweep the abdomen as well to double check the adrenal US findings?…. Sure not everyone can afford CT and i get that but prices in our neck of the woods (NJ) are coming down as we do a cavity with contrast for $850- including sedation and Dr. Ondreka radiologist read. So someone that will spend for an adrenal Sx liklely will spend < 1k on a CT for planning to be extra sure no mets and the surgeon has added confidence in the planning phase.

bhylands77

Eric
 
   I totally agree

Eric

 

   I totally agree with you with respect to high resolution CT. Remember that CT is only as good as the protocol used ( ROI, size if the slices, overlap ratio, timing of the contrast, arterial and venous phases, etc…..) and the technician who does it. What I was referring to was only specific to this case. That was because of the normal flow in the phrenicoabdominal vein and lack of a filling defect in the CVC. The CT would not add any more info to that part of the scan. If your timing of the contrast is bang on then I agree that you will get more vascularization detail especially in large breed dogs where high resolution is a stretch at the best of time. It is a real bonus when you reformat the images and can view it in anyplane or 3D reconstruction. It is light years beyond what we can do on US. It is just that you are getting decent imaging in this case to make some calls.

If this is a secreting mass then a pheo would be highest on my list but what is lacking in this imaging that would nail it is a mixed echogenic pattern. That does not seem to be present at this time. The diversity would show the same on the contrast CT with multiple patterns to it with respect to the metabolism ( intensity) of the contrast ( see the attached image).

I can probably say with good confidence that this is not secreting cortisol as there is no suppression of the cortical layering inthe oppsite gland. We discussed these possibilities together a few years ago. There have been some interesting developments since then. I would feel even more confident saying this is we had imaging of the; liver,GB, spleen, pancreas and renal cortex included. ( long story )

So if in time, this mass does not develop the mixed pattern on US which would be expected with a pheo then it might just be an adenoma . For it to be an adenoma, the echogenic density or pattern of the mass would be very homogeneous. In time as it grows, we would better be able to truly assess it’s nature by CT and  US if the resolution is excellent.

A good topic for discussion and a good excuse for another bottle of wine 🙂

 

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