Skippy has passed; 12 y/o Yorkie with likely pituitary tumor (Trilostane)

Laurie, I agree with you; even if Skippy can't survive this, we have both learned a great deal and I hope that I too can pay it forward if the opportunity arises. The general lack of knowledge about pituitary tumors, the different kinds and efforts to create medical therapies especially for dogs, surprises me. But the condition is so rare in humans and so relatively common in dogs, little research is being done. I guess we should be glad that this is a human condition too or there would be no research.

I do have a small bit of good news: took Skippy for a BP check this morning and his BP is down to 166 from 220 at the clinic. Maybe the meds, maybe the Cabergoline, maybe both, who knows! Also, he is a little more alert, responsive and interactive, probably due to lower BP. He continues to eat, drink and pee heartily and is reluctantly taking walks. I sent both Dr. Scott-Moncrieff and Dr. Bruyette an email earlier and tried succinctly (I heard you Kathy)to ask questions about continuing treatment with Cabergoline and especially about Bruyette's experience in treating with it. BTW, Dr. Bruyette has opened a diagnostic and consultation practice, https://www.veterinarydiagnosticinvestigation.com so I don't know if he will respond without a fee for consultation. We'll see and I did mention this forum.

I cannot get Skippy's diarrhea under control if I take him off the "M" drug. Local vet handed me an expensive bag of kibble to try him on.

Purdue told local vet that Skippy was a perfect candidate for their first surgery; yeah, old, high BP, a huge macro with neurological symptoms- yeah, he's perfect! Think I'll wait for Godot for the time being.

That is excellent that Skippys BP is coming down and I hope that it continues to come down even more. I'm sure he feels better when it is lower.

As time goes on, we learn more and more about the different cushings and especially macros. That there is even a possibility of something shrinking a macro would be excellent news and I think that is what Dr. Bruyette has focused on trying find. I seem to remember that from somewhere, maybe it was Kathy and her Buddy who inquired about that with him. (my memory could be faulty) but I am hopefully and I do wonder if Cabergoline will do that.

More on macro tumor/adenoma:
I had one email exchange with Dr. Bruyette yesterday; he responded immediately to my litany of questions about Cabergoline. He offered to look at Skippy's MRI and offer his opinion regarding the question of efficacy of Cabergoline for his ACTH secreting tumor and/or the appropriateness of surgery for Skippy’s macro. (I requested Skip's MRI yesterday and Purdue said they would send it immediately but I haven't received it.) Dr. Bruyette stated emphatically that the best shot for long term survival is surgery and radiation. He said that Castillo's dogs, treated with Cabergoline, had "small" tumors. Don't know but I suspect he means micro tumors. Further, he said that it is often very difficult to discern from the MRI, exactly where the tumor is located in relation to the pituitary but that he would take a look. (Dr. Scott-Moncrieff's response to this question was similar.) Multiple research studies report that Cabergoline, a dopamine agonist, works effectively to reduce the size of functional Prolactin secreting tumors in humans. Dr. Bruyette stated that Cabergoline is effective in about 20% of dogs. (I don’t know what “effective” means.) I ask Dr. Bruyette about increasing the dose; he responded that I could if it doesn’t cause gastrointestinal distress. (Skippy has been treated for diarrhea for the past month.) For info on Cabergoline in treating Prolactin secreting tumors see: http://www.vivo.colostate.edu/hbooks...prolactin.html Also, this study, https://www.ncbi.nlm.nih.gov/pubmed/1352243 states that in humans, “ In contrast to macroprolactinomas, other functioning pituitary tumors (GH-, TSH-, and ACTH-secreting) rarely shrink during dopamine agonist therapy, although the number of tumors studied is small.” However, some other studies report that prolactin is abundant in the tissue of ACTH-secreting tumors, so the effectiveness of this drug in people, let alone dogs, in shrinking ACTH secreting tumors is a major question. One article that I read, says that in humans, if Cabergoline acts to shrink the tumor, it will do so within three months of initiating treatment. Finally, another article on treatment with Cabergoline in humans, states that Cabergoline treatment must be sustained for life, otherwise the tumor will grow back.
Neither Dr. Bruyette nor Dr. Scott-Moncrieff offered any insight into the meaning of the term, “slow-growing” in describing the progression of a macro. Thus, I presume it is based on clinical signs.

I have begun to research the various approaches to radiation for pituitary tumors. There are major risks to each approach including late radiation effects, tumor regrowth, radiating good tissue, blindness, and intolerance of anesthesia, to mention a few. I will post more if I can succinctly summarize as I read more.

Surgery is an entirely different question that I have barely begun to research. Already, I have a passel of questions. One of my questions that the specialists can answer is whether the macro has invaded other parts of his brain outside the pituitary gland. Again this article is in regard to humans but presumably would apply to dogs. http://www.cancernetwork.com/review-...tuitary-tumors

If I could get to the Netherlands and Utrecht’s surgeons thought Skippy was a good candidate - and, assuming I could afford it, I would go for it. But, that’s not the hand I’ve been dealt.

Skippy will see Dr. Scott-Moncrieff in a couple of weeks if he maintains his current functioning. She will do another stim test. I will send the MRI off to Dr. Bruyette. And watch and wait.

BTW, the link listed in my last post is to Dr. Bruyette's new consulting service nationally and presumably internationally that he is offering to vets regarding internal medicine and surgery for various endocrinology related conditions. He is also offering continuing educations courses on a host of medical conditions affecting dogs and cats. (All of the courses are offered in wonderful fun places!) I think the vet consultation service is terrific and the cost is reasonable, especially if the appalling lack of knowledge about Cushing's is indicative of the sorry state of too many vet's level of knowledge in general.

Most of our Cushing's dogs are older as are some of their owners, including me. To that end, here is my final link for the weekend written by Dave Bruyette, https://media.wix.com/ugd/38e433_6df...67672e512c.pdf and addresses the aging pet. :)

Hey Carole, once you get the imaging to him, I think Dr. B's opinion re: Skippy's suitability as a surgical candidate will be invaluable. Just wanted to make sure you're aware that he has pioneered surgical intervention himself, at U.C.L.A. His first patient, Lucy, was a treasured member here:

http://dogaware.com/articles/newscushingssurgery.html

Lucy's mom hasn't posted for several years, but she might respond to a PM if you wanted more info about their surgical experience. Here's her profile page:

http://www.k9cushings.com/forum/member.php?u=35

Marianne

Thank you Marianne, I have heard plenty of mentions about Lucy Goo but have not looked up her thread. I will do so. I don't think Dr. Bruyette is still practicing but I could be wrong. Also, I'm aware that he was trained by or trained with neurosurgeons. Dr. Bentley at Purdue has a fine reputation locally and was trained by Washington State but he has never performed the surgery. Utrecht folk clearly state that the experience of their surgeons over time (since 1983 ) has made a significant statistical difference in survival rates of their dogs, although with the introduction of Vetoryl, they are now seeing more dogs referred with large macros for whom the prognosis is not nearly as good.

Skippy Update: I haven't posted an update for awhile as I often find myself at a loss for words regarding Skippy's condition. But some folks may be interested in the boy's response to Cabergoline. Overall, and after a month, I would describe him as modestly improved relative to his condition back in March and early April when he was diagnosed with the macro and I stopped the Vetoryl. The research suggests that Cabergoline may work on tumors that secrete cortisol AND prolactin. Dr. Bruyette reviewed Skippy's MRI and stated that he thinks that Skippy's tumor "is coming from the pars distalis and not the pars intermedia given the vasopressin signal seen on the sagittal T1 images so I don't know if Cabergoline will be of much help." He did say that he thought Skip was a good candidate for surgery or radiation as the tumor has "minimal expression caudally past the dorsum sella."

Skippy is walking more, has picked up a ball a time or two, is ravenous, peeing and drinking in full Cushing's mode, is still lethargic though less so. Tremoring is greatly diminished although still present when stressed and many things stress him. He is having balance problems and back leg weakness continues to progress. His skin remains crepey but his hair has grown back; he has new lumps monthly but the adenoma on his butt doesn't appear to be growing. He is more interactive but not nearly where he was before Vetoryl. I will have his BP checked this week. I cannot get the soft stool to diarrhea under control and Dr. Bruyette mentioned gastrointestinal issues as a side effect of the Cabergoline. Once, I accidently gave him a full tablet of the stuff and he reacted with severe tremoring for a couple of days so I won't be increasing his dose.

Skippy sees Dr. Scott-Moncrieff on May 23rd; she wants a Stim test and I guess it is my call as to whether or where we go next. I have taken a break from researching radiation as the technical complexities of different equipment, protocols for dosage and number of treatments are well beyond my pay grade. (There is an entire website devoted to the different types of radiation equipment available at different vet schools throughout the US.) I am inclined to talk to U of Wisconsin where they utilize Tomotherapy, because of geographic access and their equipment is state of the art; and the MRI is attached to their radiation equipment. I have ruled out surgery for Skippy; his tumor is too big, symptoms are too severe and last but not least, Purdue's surgeon has never removed a pituitary tumor. I have not ruled out keeping him on the Cabergoline and doing nothing more depending on his test results. But honestly, I am worn down with Skippy's maintenance, treatment, research, watching, worrying over every symptom and obsessing over what to do next. Wondering if he will die or I will need to put him down if he has a crisis, I am somewhat numbed by the experience at this point. I love this little guy dearly and I will do all that I can to improve his quality of life or walk the road with him to wherever it ends.

This is overall a very encouraging report. Thanks so much for updating.:o

Hang in there Skippy! We re pulling for you! I love to see positive results, particularly when a macro is involved.

Kathy

Hi Carole,

I am glad to read this update. Seems Skippy's quality of life is improved some and that is all we can hope for.

I relate to the exhaustion of this condition - it is literally consuming all of my time. I am so grateful I have the time and resources to care for my Mojo, but to be honest this is wearing me down. Everyday is an emotional roller-coaster. I find myself wondering at least a few times a day if it is just more humane to let him go ... but his eyes are clear, he is full of love, and can still do most "dog" things albeit in different ways then when he was healthy.

I pray I will know when the time is right - I've put down a few dogs in my time and always known when enough was enough. I am not a selfish pet owner and always put their needs and comfort ahead of my own and I don't keep them here when they are suffering. But with this illness, it is just enough suffering to make us all miserable but not enough to give me that moment of clarity when I know it is time.

I am truly prepared for what is to come - but I just wish I had a more clear path. The constant emotional upheaval is not good for either of us.

Hang in there - I pray for you, me and all the Cushing's parents out there. It is not an easy road we walk ...

ETA: that is my little man in my avatar. I finally figured out how to post it.

Having just been in the watching, waiting, worrying mode myself I can understand how you feel. It's all consuming and tears you apart inside. I tried my best to prepare myself for the inevitable but it's still so hard. It's out of our hands, so you just keep doing what you're doing-love them, hug them and make them happy. They know, they feel our love. All the best to you and Skippy.

I'm really glad to hear that Skippy is appearing to be a bit happier these days, even if sometimes lethargic.
It IS all consuming. No doubt about it and the worst the issue you are dealing with and the symptoms, the more complicated, the more consuming it is.
Skippy sure fits all that.