Adrenalectomy in a Golden Retriever Betty Lobanov Jan 29th 2014 Signalment & History • 10 year old female spayed Golden Retriever •Presented to CUHA Soft Tissue Surgery service for adrenalectomy • Presenting complaints to rDVM 2 months prior •Polyphagia •Polyuria •Alopecia •Muscle atrophy Problem List • Alopecia ▫ Primary dermatologic, Endocrine, Immune mediated • Polyphagia ▫ Endocrine • Polyuria ▫ Endocrine, Renal disease, Hypercalcemia, Diuresis, Pyelonephritis, Psychogenic • Muscle atrophy ▫ Degenerative, Endocrine, Nutritional, Immune mediated, Neurologic, Orthopedic Diagnostics • Senior wellness exam April 2013 ▫ ▫ ▫ ▫ ▫ CBC: mild lymphopenia Chem: ↑cholesterol, ↑triglycerides T4: WNL Urinalysis: 2+ proteinuria USG 1.016 • USG & urine protein re-checks recommended ▫ 3+ proteinuria, USG 1.036 • Proteinuria still persisted recommended urine protein:creatinine (UPC), blood pressure, urine culture/sensitivity ▫ UPC 1.3 (normal < 0.5) ▫ Culture/Sensitivity: No growth ▫ Monitor & re-check in 4 months Diagnostics • Re-check August 2013 ▫ CBC: lymphopenia, eosinopenia ▫ Chem: ↑cholesterol, ↑triglycerides ▫ Urine culture/sensitivity: E.coli organisms Amoxicillin 400mg Re-check 5-7 days after termination of therapy no growth Problem List • Alopecia ▫ Primary dermatologic, Endocrine, Immune mediated • Polyphagia ▫ Endocrine • Polyuria ▫ Endocrine, Renal disease, Hypercalcemia, Diuresis, Pyelonephritis, Psychogenic • Muscle atrophy ▫ Degenerative, Endocrine, Nutritional, Immune mediated, Neurologic, Orthopedic But wait, there’s more… • Dermatologic punch biopsy 7/12/13 Calcinosis cutis • Abdominal ultrasound 7/30/13 adrenal mass • ACTH stimulation test ▫ Screening test ▫ Confirmatory test ▫ Evaluates ability of adrenal gland to secrete cortisol after maximal stimulation ▫ Protocol serum cortisol collected for baseline and 1 hour after administering 0.25 mg synthetic ACTH IM serum cortisol collected for baseline and 2 hours after administering 2.2 U/kg ACTH gel IM Hyperadrenocorticism [HAC] Time vs. Cortisol • Patient’s ACTH stim consistent with Cushing’s (hyperadrenocorticism) ▫ Pre 5.0ug/dL (ref 1.8-4) ▫ Post > 50ug/dL (ref 6-16) • Low Dose Dexamethasone Suppression Test (LDDS) ▫ ▫ ▫ ▫ ▫ Differentiating test Pre 3.8ug/dL Post 4hr: 1.5ug/dL (healthy dog < 1ug/dL) Post 8hr: 2.3ug/dL Protocol Baseline blood sample for cortisol Inject 0.01 mg/kg dexamethasone obtain blood sample at 4 & 8hr LDDS Test Time vs. Cortisol • Medical management: Trilostane ▫ PDH, ADH ▫ Competitive inhibition of steroid synthesis 3β-hydroxysteroid dehydrogenase ▫ Daily doses needed ▫ Cats, Dogs, Birds • Re-check cortisol levels post initiating Trilostane ▫ ACTH stim Pre 1.9ug/dL (ref 1.8-4) Post 2.4ug/dL (ref 6-16) ▫ Trilostane decreased from 60mg to 30mg Hyperadrenocorticism (Cushing’s) • 3 types –treated differently and different prognosis • Pituitary dependent hyperadrenocorticism (PDH) ▫ 85%-90%; overproduction ACTH ▫ Can live normal lives for many years with medical management (controlling adrenal gland) ▫ 15% neurological signs Macroadenomas > 1cm in diameter Microadenomas < 1cm in diameter • Adrenal dependent hyperadrencocorticism (ADH) ▫ Functional tumor on the adrenal cortex ▫ Adenoma or carcinoma ▫ Benign surgical removal, curative ▫ Malignant surgical removal may help but prognosis guardedpoor • Iatrogenic ▫ Excessive administration of an oral or injectable steroid Hyperadrenocorticism (Cushing’s) Adrenal Architecture & Products Back to our visit • 9/24/13 CUHA Soft Tissue Surgery • Physical exam ▫ ▫ ▫ ▫ ▫ ▫ T: 101.8°F P: 108bpm R: 32bpm 23.5kg BAR Bilateral alopecia around the elbows Hindlimb muscle atrophy Healing sebaceous cyst on right hindlimb Pre-op Diagnostics • • • • CBC Chemistry panel Abdominal ultrasound Thoracic radiograph RESULTS: CBC: no significant findings Chem: ↑cholesterol 557mg/dL (ref 138-332mg/dL) ↑triglycerides 314mg/dL (ref 22-125mg/dL) Abdominal U/S: caudal pole of left adrenal gland hyperechoic mass; right adrenal gland normal Thoracic radiographs: no evidence of metastases Surgical Approaches • Ventral midline ▫ Dorsal recumbency, surgically prepped ▫ Xiphoid-pubis incision Surgical Approaches • Paralumbar ▫ Lateral recumbency, surgically prepped ▫ Lateral vertebral process-within 3-4cm of ventral midline incision (caudal to 13th rib) Surgical Approaches • Laparoscopic ▫ Lateral/near-lateral with affected gland up, surgically prepped ▫ Endoscopic tower directly opposite surgeon facing patient’s back ▫ 3 or 4 port technique; Instrument ports are placed in a triangulating pattern around the location of the adrenal gland Approach Pros Cons Ventral midline -Standard approach -Enhanced visualization for exploratory/metastatic evaluation -Exposure of both adrenal glands -Dehiscence -Exposure & dissection may be difficult in large dogs Paralumbar -Better access to adrenal gland -Minimal dissection and damage to pancreas -Limited metastatic evaluation -Dehiscence Laparoscopic -Minimally invasive -Decreased pain -Less risk of dehiscence, wound infection -Shorter hospitalization -Ability to address complications compromised - Profuse hemorrhage possible Exposure via Paralumbar 9/25/13 Surgery Day • Exploratory laparotomy & Left adrenalectomy ▫ Xiphoid-pubis incision ▫ Abdominal exploration: unremarkable ▫ Mass identified & dissected Right angle forceps, tenotomy scissors, bipolar electrocautery (hemostasis) ▫ Phrenicoabdominal vein ligated with hemoclips ▫ 2 layer closure ▫ Skin staples & Tegaderm patch • Intra-op Dexamethasone IV Post-operative Care • 9/25/13 ▫ ▫ ▫ ▫ Dexamethasone IV Plasmalyte fluids IV Fentanyl CRI Fragmin SQ • 9/26/13 ▫ Plasmalyte fluids IV ▫ Fentanyl patch ▫ ACTH stim Pre 0.25ug/dL (ref 1.8-4) Post 3.74ug/dL (ref 6-16) ▫ Discontinued Fragmin • 9/27/13 ▫ ▫ ▫ ▫ Discontinued Hetastarch & Fentanyl CRI Prednisone 5mg PO Omeprazole 20mg PO PT/PTT • Discharged 9/28/13 Complications • Addisonian crisis ▫ Hypoadrenocorticism ▫ Lack of aldosterone • • • • Hemorrhage Fluid & electrolyte imbalances Pulmonary thromboembolism Delayed wound healing Histopathology ◦ ADRENAL MASS Dx: Locally extensive cortical adenoma NORMAL Adrenal Neoplasia • Adrenocortical ▫ Adrenal carcinoma ▫ Adrenal adenoma • Pheochromocytoma: catecholamine secreting tumors arising from medullary tissue • Clinical signs due to nonfunctional tumors are caused by local invasion of the tumor into surrounding tissue, distant metastases, or both • Functional tumors secrete excessive amounts of cortisol, which inhibits pituitary ACTH secretion and causes atrophy of the contralateral adrenal gland Adrenal Neoplasia • Adrenocortical adenomas and carcinomas appear to occur with equal frequency • Usually unilateral • Complications ▫ Adrenal insufficiency ▫ Pulmonary thromboembolism ▫ Pancreatitis Post op 2.5-11% (Schwartz 2008) Increase in manipulation due to invasive tumor ▫ Recurrence Clinical signs related to HAC within 3 years ~ 33% (Axlund 2003) Cost • Visit + Specialty exam = $123 • Diagnostics = $579 • Surgery & Anesthesia = $1,113 ▫ Adrenalectomy = $462 ▫ Isoflurane = $206 Total: $3,780.68 • Hospitalization = $1,219 ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ ICU Maintenance = $165 + $165 Cosynotropin $62 ACTH stim = $29.48 PT/PTT = $80 Fragmin = $110 + $216 BP monitoring = 3 x $32 = $96 Gaslyte monitoring = $64 + $96 + $64 PCV/TP = 2 x $36 Patient follow-up • 10/8/13 re-check at CUHA Soft Tissue Surgery Service ▫ Ravenous appetite diminished ▫ Discontinued Omeprazole and Fentanyl patch ▫ Taking Prednisone • 10/23/13 ▫ rDVM call: doing well clinically, taking Prednisone EOD ▫ ACTH stim Pre 3.4ug/dL (ref 1.8-4) Post 14.2ug/dL (ref 6-16) Thank you to my advisors: Dr. Harvey Dr. Jay Resources • Axlund TW, Behrend EN: Surgical Treatment of Canine Hyperadrenocorticism, Vol. 25, No. 5, May 2003 • Feldman EC, Nelson RW: Hyperadrenocorticism (Cushing’s syndrome), in Feldman BF, Nelson RW (eds): Canine and Feline Endocrinology and Reproduction, ed 2. Philadelphia, WB Saunders, 1996, pp 187-265 • Fossum, Theresa. Small Animal Surgery, 3rd edition. St.Louis: Mosby Inc., 2007 • http://www.vsso.org/Adrenal_Cortical_Tumor.html • Massari F, Nicoli S, et al. Adrenalectomy in dogs with adrenal gland tumors: 52 cases (2002-2008). J Am Vet Med Assoc 2011; 239:216-221 • Pelaez MJ, Bouvy BM, Dupre GP: Laparoscopic adrenalectomy for treatment of unilateral adrenocortical carcinomas: Techniques, complications and results in seven dogs. Vet Surg 2008;37:444-453 • Schwartz P, Kovak JR, Koprowski A, et al. Evaluation of prognostic factors in the surgical treatment of adrenal gland tumors in dogs: 41 cases (19992005). J Am Vet Med Assoc 2008; 232:77-84 Questions?