Lucygoo - Pit. macroadenoma, endoscopic transsphenoidal surgery, trans-oral approach

Hi all....

Thanks, Marianne. I think I've already made the decision to go with the surgery, if it's operable. (That's why we're getting the MRI) I think I'm fortunate to have Dr. Bruyette here, and if it's successful, and she doesn't die during the surgery...which is always a possibility...the Cushings will be cured. She won't have to be subjected to triolstane or fasting ACTH stim tests any more...and even if she only has a few months left, at least it will give her a chance of being comfortable. I can't take watching her not eat...at least she's still drinking.

The reason why they know it's a macrotumor is the symptoms, and how her loss of appetitie came on gradually...He said it happens in a small percentage of cushings dogs, but it does happen...we just happen to be lucky, I guess;)

Thanks for your input everyone. I don't know if I'm making the right decision or not, but I just dont' want this thing to grow anymore and cause her any more suffering.....

I'm so sorry to hear that Lucy has a macro - I too had suspected that was likely the case when I read about her symptoms.

It is great to see that they are now doing surgery on macros. I believe the surgery that is done in Europe is really only done when the tumor is a micro tumor or at least the tumor is at an early stage and has not yet enlarged to an extent to cause neuro symptoms - so it looks like this is a slightly different type of surgery. In Europe, they do the surgery when the dog is first diagnosed with Cushing's and it "cures" the disease but I believe that once a dog has an established macro they won't/can't operate. Once the entire pituitary is removed dog however, needs to be on a small maintenance dose of prednisone (because the pituitary is no longer there to "tell" the adrenals to make cortisol) as well as thyroid meds (because the pituitary also tells the thyroid to do its job). I think they can have central diabetes insipidus at least for a while after the surgery too - but I'm not at all sure about that.

The very best of luck with what lies ahead for you and Lucy and do keep us updated (I know you will!;):))

Alison

PS: Do you know if, with this surgery that Lucy will likely be having, they aim to remove the entire pituitary once and for all or if they are just trying to remove the tumor? I'm pretty sure in humans that they try to only remove the tumor and leave the healthy pituitary behind - because removing the pituitary also affects the production of sex hormones which with a dog is not a problem.

Alison....that's what the MRI will tell, size of the tumor, etc. He did say if it's large enough, they will remove the whole pituitary, and she will be on a dose of prednisone and something else for the rest of her life. I'm pretty sure that's what they'll do, especially if it's already pressing on "things," i.e., appetite. But we'll see, I guess.
I just feel I should take advantage of this free surgery..at Cedars, no less! I just think if it were me, I'd want someone to do the same thing for me. I'd much rather die on the table than go through being senile and not have the sense to even eat. And my Goo (Lucy) has so much personality..she even smiles:) I hate to see that go, too.
I trust this guy too. When I said to go ahead and do the MRI, I asked him, "Is that what you would do?" And he said, "Yeah, definitely. At least you'll know." So I guess we'll see on Monday. If it's not operable for whatever reason...we'll do the palliative, I guess, or try the Canadian drug, or both...and see what happens. At this point I'm just crossing my fingers that it's operative. I think it's a good gamble, as Marianne says.

Love to all,
Gina and Lucy

Hi Gina,

My first dog as an adult was a black lab/german shepherd mix named Buffaloe. He was an unbelievably great dog, off the charts. I think Lucy could have a couple of more good, happy years in her if she gets healthy.

I have to preface this by saying, I am a believer in surgery in many cases. My Dad was a surgeon. I played professional football until I was 33 and have needed several surgeries. And my dog (german shepherd/collie mix) had a very large, malignant adrenal tumor surgically removed in 2006 and is doing great today at 14 1/2. She was doing very poorly before her surgery and the adrenalectomy provided her a complete cure. The surgery was risky but it was a risk we had to take.

Obviously, you will need to find out from the MRI whether Lucy's pituitary tumor is operable. I hope the surgeon is highly skilled and has some good experience in this type of surgery. You have quite a bit of additional information to gather before your difficult decision. It sounds like you are in a similar situation as me before Shiloh's surgery. For me, it was an easy decision. Shiloh was just hanging on, had no quality of life and would have died soon...plus her last few months would have been miserable. I know if Shi would have understood the situation she'd have said, "come on Dad, let's have the surgery." But it was a very difficult, emotional thing for me. The day of her surgery was the toughest day I've gone through in many years.

My surgeon told me that the only people in my situation who should not have the surgery (adrenalectomy) are those who could not handle it if their dog died. His words probably hold true for you as well. You have to be convinced you are doing the right thing. All the best whatever way you proceed.

Ken

Ken, Thank you so much...that's the best success story I've heard! Shilo doing great at 14 1/2:) Lucy's still her old self to a point, but I hope I caught it early enough, and I hope the tumor's even operable. She ate a little tonight, but only if I hand feed her. (My hands now permanently smell of mushy, fishy, dogfood...but what do I care.)
I'm hoping now that the MRI shows that it's operable....I'd hate to see her decline to the point of not even drinking water any more.

Dr. Bruyette said that if I decide to go the surgery route, he'd have a whole packet of materials for me...yikes!....and I'll pass it on to you guys, as well. Maybe it will be beneificial to someone.

Thank you everyone for your support....I'm sure I'll be checking in all night and all weekend long....and Dr. Bruyette said I can e-mail him anytime this weekend if things get weird....he's so cool.

Ciao:)

Lucy and Gina...

Gina,
I'm glad that Lucy had a good visit with Dr Bruyette. And it sounds like you have carefully thought this through. I am also glad then Ken was here to tell you about Shiloh. I was going to write you about her, and tell you his philosophy about surgery. Very sound advice. Will this surgery help my dog and am I willing to risk the surgery and losing my dog in order for her to have a better life. It would be painful to lose one in surgery, but also very painful to see them slowly deteriorate and lose all their self esteem.
You have a long weekend ahead of you, waiting for the MRI on Monday, as do we. It sounds kinda crazy to wish for a turmor so Lucy can have the surgery and be cured. And to think that Lucy will be part of helping future cushings dogs by participating in the surgery. All those that follow can be thankful to her.
Try to get some rest this weekend.
Sending healing thoughts and prayers for Lucy.
~ Mary Ann

Hi Gina,

I'm not sure if anyone has given you this link yet, but it might be helpful for you to read if you are considering having the surgery done (removal of the pituitary gland, also known as Hypophysectomy). I wonder if maybe the surgery that Dr. Bruyette is recommending as a possiblity for your dog is the surgical technique recently described by Dr. Todd Axlund?

The full article is on page 1 of the newsletter linked below and it is called:

Axlund’s Pioneering Treatment for Cushing’s Disease
By Todd Axlund, DVM, MS, ACVIM (Neurology)

http://www.metropolitanvet.com/media...Newsletter.pdf

In the article, Hypophysectomy and Dr. Axlund's new technique for performing the surgery is described.

Quote:

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Dr. Axlund at Ohio Veterinary Surgery and Neurology developed a new approach to the pituitary gland during his faculty tenure at Auburn University College of Veterinary Medicine. His research has been published in Veterinary Surgery and presented at national veterinary conferences. Previous surgical approaches access the sphenoid bone through an open mouth. Dr. Axlund instead makes a small paramandibular incision through the ventral neck. Once the mandibular and glossal soft tissues have been retracted and the sphenoid visualized, the bone is carefully removed just ventral to the pituitary gland. The precise nature of this procedure requires exact localization of the gland using either CT or MRI (figures 1-4).

Once the pituitary is reached, the entire hypophysis is removed by manual extirpation or by ultrasonic surgical aspiration. Removal of the tumor alone would be ideal, however, the limited field of view and small size of the mass make it visually indistinct from the normal pituitary. Therefore, the entire gland is removed and the patient is supplemented post-operatively with the necessary hormones.

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and

Quote:

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Hypophysectomies have been performed as a matter of routine in the Netherlands for a number of years and have offered encouraging results. Forty-three out of the first 52 clinical cases went into clinical remission after hypophysectomy. Of these 43 cases, all but five cases remained in remission for the duration of the study (two years) and required no further treatment for Cushing’s disease. Dr. Axlund’s personal experience with his technique is similar to that of published reports. While this treatment is not curative in every case of pituitary dependant hyperadrenocorticsm, the success rate and relative safety of this procedure make it a viable alternative to standard medical therapy in many cases.

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I'm not sure what the surgery is...but thanks for that link. (Sounds like that's probably what it is.) I'll know more on Monday. Of course now I'm having second thoughts on everything. I'm thinking things like....they just want to use her as a test subject, and it won't matter to them if she comes through or not, and what she'll be like if she does survive. She just seems so unhappy today. I couldn't even get her interested in a squirrel in the back yard....although she was very much interested in a cat on our measly little walk..she actually tried to chase it. It just breaks my heart to see her deteriorate so fast. I just want to do the right thing for her.

Thanks for listening everyone....
Gina and Lucy

How is the eating going?

It occurred to me that if she is drinking well - even excessively - then maybe you can use this to get some calories into her by giving her "soup" to drink - even that special puppy milk you can buy could be good. Also cultured (must be cultured) buttermilk is meant to be good too.

Hopefully the rising cortisol will kick in and reduce swelling inside her brain and some of the symptoms will ease - did the Dr. mention the possibility of giving her additional pred if it looks like her cortisol isn't rising high enough fast enough (sometimes it can remain a bit suppressed for a while after Trilostane - it varies from dog to dog and even time to time, it seems.)

Alison

Hi Gina,

I think you just need to hang loose and enjoy the rest of your week-end with sweet Lucy. You have a long ways to go before being in a position of making a decision. You need to find out for sure whether or not Lucy has a macro pituitary tumor and if it's operable. The professionals also would have to think Lucy is a good surgical candidate. Then you would need to meet with the surgeon, find out his/her experience with this type of surgery, success rates, risks, etc. Please don't feel any stress now.

I do think it is wonderful that you may have the option of having the surgery and a complete cure. That's a very good deal. I never understood why they weren't doing these surgeries in the U.S., only in the Netherlands.

I'm glad that Lucy still has a pretty good quality of life. You have ALOT of information to gather before you have to make a decision and there's no big hurry. Hang real loose, have some fun and enjoy Lucy...please give her a kiss and belly rub from Shi and me.

Ken