Possible pituitary removal surgery for Cushing's with Dr. McCue at Animal Medical Center in NYC

Discussion in 'Acromegaly / IAA / Cushings Cats' started by Ana & Frosty (GA), Aug 4, 2018.

  1. Ana & Frosty (GA)

    Ana & Frosty (GA) Member

    Joined:
    Jan 19, 2018
    Hello all,

    It has been a busy week! I had a 40 minute conversation with Dr. McCue about possible surgery on Thursday, and finally have some time to write about it. I have learned a lot about both treatment options (medication vs. surgery), and want to share with you for those who may be diagnosed in the future.

    First, a little bit about the program at AMC. It appears that someone donated money to establish a pituitary surgery program at the hospital. I don't know who did, or why, but you can consider it almost like a grant towards the program, although I am not sure if this was a private donation, or from administration, or some association on pituitary disease (do those exist?), or what. Doesn't really matter for our intents and purposes. ;)

    So the money that has been donated helps subsidize the surgery, like @Amanda & Shmee has mentioned in her posts. This makes it much more affordable, since the surgery costs about $15,000-20,000, and we would only have to pay $3000. When I spoke with Dr. McCue, he said that the finances are still there, and like Amanda said, the $3000 covers the initial consultation with the surgeon, the necessary brain imaging studies (CT or MRI), and the echocardiogram (ultrasound of the heart). The actual surgery, the ICU stay, and the imaging he would need to have after surgery are covered by the donation.

    Like Amanda has also told us, they have so far removed 5 pituitaries in cats - Shmee will be the 6ths.
    These include 2 cats with Acromegaly, 2 with large pituitary tumors that not secreting anything but causing neurological symptoms, and 1 with Cushing's. To make matters more complex for the Cushing's parents, the Cushing's kitty is only 1 month post-op. :nailbiting: He said she is doing well so far, but there is really no long term information what so ever. Only 1 kitty did not do well after surgery, and that kitty had the large tumor with neurological symptoms. Very sad nonetheless.

    The Cushing's kitty that had surgery did not have skin tears - her major issue was insulin resistance. The owner opted not to start her on Vetoryl, and proceed with surgery right away. Given Frosty's initial skin issues, Dr. McCue said that it is a good thing that he started and responded well to the medicine, as it would help him heal from surgery if he were to have it.

    Timing of surgery: I have read in the articles that occasionally, vets use Vetoryl as a bridge between diagnosis and surgery, since the extra cortisol can negatively impact wound healing in Cushing's cats. I asked Dr. McCue whether he would want Frosty to be on Vetoryl for a particular length of time (6 months for example) prior to performing the surgery. He said no, especially since it sounds like Frosty is already responding well to the medication from what I had told him. Of course, I realize that he would need to examine him before giving the ultimate answer. He said I could bring Frosty in for a consultation as early as 1st week of September, and he could have surgery the following Tuesday! :nailbiting:

    What tests are needed before surgery?
    A physical exam, and as Amanda already mentioned, a brain MRI to see the tumor, and an echocardiogram to make sure the cat's heart is healthy enough to undergo anesthesia for the MRI and the surgery itself. He said the prevalence of hypertrophic cardiomyopathy is greater in cats with Acromegaly due to the nature of the disease (everything tends to enlarge due to the Growth Hormone, hypertrophic means large or over-developed). He did no really mentioned the prevalence of heart disease it in Cushing's disease, but obviously any metabolic abnormality makes you worry about integrity of any tissue or organ. He said that usually, if you do not hear a murmur, the heart is likely fine. Interstingly, I have been told that Frosty has a murmur by some vets, and that he doesn't by others. Sometimes they have "flow murmurs" if they are nervous, so I am not really sure if this is a real murmur or not. Blood work? may also be probably done, although I did not ask about that specifically.

    Since this is an elective surgery, meaning it is not done for an emergency condition that is threatening the life of the cat at THIS VERY MOMENT, the cat should be the best health it can be before undergoing it to give chances for the best outcome.

    The surgery itself - how do they remove such a small gland from a small cat?: The way they do the surgery is similar as to how they do it in humans (which I actually didn't know anything about because I never did a rotation in neurosurgery). The main difference is that in humans they do it through the nose, and in the cat they do it through their soft palate, since their nose is so tiny. Also, in humans they don't always remove the whole gland, but in cats the difference between tumor tissue and normal pituitary tissue is so difficult to tell apart that the best thing to do is to remove the entire gland.

    SO, Apparently, in addition to a regular MRI, they do some additional imaging (I can't remember if it's an MRI or CT scan) where they put markers on top of the cat's head and map out the brain in 3D. Then, during surgery, they put the same markers on the cat's head, and use the 3D image from the scan =like a navigation system to help them get to the correct part of the brain where the pituitary lies. In addition to this, they use endoscopy to assist them in viewing the tumor (a camera in the cat's mouth), which helps blow up the area and shows it on a high definition (HD) screen. So they have these 2 screens in front of them to help them perform the surgery, which is pretty cool and modern.

    What are some possible risks associated with the surgery?
    One thing that cat happen is dehiscence of the surgical wound, which is in the mouth. This is due to the fact that the cat has to eat. If this were to happen, symptoms would be a sinus infection, since they do the surgery through the sinus. This would require a re-operation to close the wound, and antibiotics for infection.

    How long does the surgery take?
    The surgery itself takes between 3-6 hours, all depending on the tumor size, location, etc. A part of the time is for the positioning - this takes a while because they have to position the cat and markers on his head properly in order to be able to use the navigation system.

    What is recovery like?
    So recovery not only depends on the surgery itself, but on the over-all health of the cat. A typical recovery for an OTHERWISE health cat who has no heart, kidney, or healing issues is 5-7 days in the ICU, after which they can go home. However, things like heart disease can prolong recovery if the heart is stressed during the surgery, and may require an additional week to recover. Luckily, form the financial standpoint, it doesn't really matter since the donation will cover all the hospitalization costs.

    Does the surgery provide total cure, and for how long?
    This is the interesting, and complicated part. Initially, surgery removes the entire pituitary gland, including the tumor that is secreting extra Cortisol, thereby curing him immediately. HOWEVER - sometimes, tumor cells are still left behind inside the bone, and over the years they COULD potentially become active again, and start secreting excess cortisol. He said at a 5 year follow up in both dogs and people about 65-75% of them are still in remission after surgery. But the other 25-35% can have recurrence of Cushing's symptoms.

    And this is data on dogs and people with Cushing's. No data really in cats with Cushing's.

    (Like @Chris & China said... no guarantees in life, ever).

    What medication will the cat need after surgery?
    Amanda already went over this in her posts, but the pituitary is responsible for 3 hormones - cortisol, thyroid, and anti-diuretic hormone (ADH). The pituitary sends signals to the thyroid glad and the adrenal gland to make these hormones.

    IF the pituitary tumor is relatively small, the adrenals can usually eventually produce the appropriate amount of the ADH on their own, without the pituitary. However, in some cases, if the tumor is really large, the cat will need AHD supplementation. That can be given as a pill, as an injection, or as an eye drop.

    The other 2 - cortisol and thyroid hormone need to be supplemented. They are oral medications, and he said they are usually tolerated well since they are just hormones replacements.

    So the cat will still have to take medication and/or get injections every single day for the rest of their life.

    What is the follow up after surgery like?
    The follow up after surgery is similar to the follow up schedule the kitty has while on Vetoryl - first every week, then 2 weeks, then every 3 months for the rest of their life.

    Additionally, the kitty would need to have MRIs to evaluate the surgery effect - at 3 months, 6 months, 9 months, and a year. These require general anesthesia.

    Will they be publishing this data?
    YES! This is a really exciting part, because thanks to this donation, they can perform these surgeries and then evaluate whether or not they are an effective treatment for Cushing's! So there will actually be some information about these surgeries and whether they are effective and a good treatment options for cats with pituitary tumors. However, the down side, of course, is that there is very little data on this RIGHT NOW, and we don't know if this will help or potentially hurt.

    Attached is my Pros and Cons list of Vetoryl Vs. Hypophysectomy for Cushing's disease.

    Thanks for reading!!! Any input/advice is greatly appreciated on this!
     

    Attached Files:

    Last edited: Aug 4, 2018
  2. Ana & Frosty (GA)

    Ana & Frosty (GA) Member

    Joined:
    Jan 19, 2018
  3. JeffJ

    JeffJ Well-Known Member

    Joined:
    Jul 7, 2016
    Excellent writeup Ana. This SHOULD BECOME A STICKY. Can we ask a moderator to do that?

    Also, what a wonderful donor. Putting their money to a good cause helping sick cats. Very commendable.
     
  4. Amanda & Shmee

    Amanda & Shmee Well-Known Member

    Joined:
    Feb 18, 2018
    Thanks for typing all this out Ana!

    I had no idea about the possibility of the tumor cells returning, and the need for additional MRI's in the future... which is very discouraging to me. We specifically talked about post-care, I told him we do not do well with pills, and he told me "These can be supplemented as either a liquid or a pill. In some cases we can make a chewable tablet that some cats will eat." I do not want to do pills every day, this was a big concern for me... I really hope the liquid is available and easily added to food or something :(

    I already thought getting bloodwork done every three months for the rest of his life was excessive, four $2500 MRI's in the year following surgery is not an option for me, and he did not mention this at all when we talked for over an hour an on the phone or any emails. I wonder what "requirement" really means now.... especially since this is for a study. Are we going to have to sign something to ensure we do these post MRIs or they will charge us? I will be emailing Dr. McCue, feeling discouraged now...
     
  5. Ana & Frosty (GA)

    Ana & Frosty (GA) Member

    Joined:
    Jan 19, 2018
    Oh no! I dont want you to feel discouraged!! The follow up MRIs are covered by the donation, you do not have to pay for that! He said it is to make sure everything looks good after surgery. He also said follow up can be done locally as well, so you can take Shmee to a local animal hospital or vet for the follow up blood work. We can probably just email him the results,

    As for the medication form, I am sure there are liquids available as well! You should definitely ask him to clarify whatever questions you have, but I think you guys should be fine. :) I mix Frosty’s current meds (capsule and half a pill) into his food and he eats it no problem most of the time. Occasionally he leaves the Pepcid behind - I have a feeling it’s probably bitter or something, but then I give it to him with a treat.

    Please let me know what Dr. McCue says. Hugs
     
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  6. Ana & Frosty (GA)

    Ana & Frosty (GA) Member

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    Jan 19, 2018
    Also, there may be some differences between Cushing’s and Acromegaly cat tumors. I do not know if the Acromegaly tumor cells behave the same as Cushing’s tumor cells, so recurrence with Acromegaly may not be the same as with Cushing’s.

    Also, it’s important to note that sometimes there is also recurrence with SRT, so I personally think surgery is probably a better chance for cure.
     
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  7. Amanda & Shmee

    Amanda & Shmee Well-Known Member

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    Feb 18, 2018
    Thank you!! There are so many details here, I get so anxious. And I do not live close to NYC, I am driving through the night to get there. That is amazing that the post-MRIs are covered :eek:, but I assume they would have to be at NYC and they arent going to give me $ to have them done in Cleveland. I did just send him an email though to clarify. I really do not like that he didn't tell me about the possibility of the tumor cells returning... that is very odd. But then again my Shmee does not have Cushings, so that might have something do with it but he still has the tumor/growth hormones so I don't see why he would not have told me. We shall see. 65-75% still in remission after five years is still good, but something he should have told me.
     
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  8. Amanda & Shmee

    Amanda & Shmee Well-Known Member

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    Feb 18, 2018
    Very true, without risk there is no reward.
     
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  9. Ana & Frosty (GA)

    Ana & Frosty (GA) Member

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    Jan 19, 2018
    I hear you. There’s definitely a lot of information to go over, and I hope recurrence is lower with Acromegaly. It might be. I pulled up some article from Thailand today from 2015 which said that cats tend to do better with the surgery if they have Acro vs. cushing’s. I don’t know if they meant in the short term, but should probably post it here so people interested could read.

    I didn’t find many journal articles about the surgery when I looked today. I even went to the RVC website, and they just said that they do this surgery, and it’s not very common. That we already knew. There was another article from 2001 but I couldn’t get the full text. I searched for “hypophysectomy Cushing’s cat” on google.
     
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  10. Ana & Frosty (GA)

    Ana & Frosty (GA) Member

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    Jan 19, 2018
    I know the drive is far for you, but maybe we can talk and arrange for u to stay here for a day if you have to come back for the follow up MRIs? We are in NJ an hour away from NYC. I can talk to my bf about that later.
     
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  11. Amanda & Shmee

    Amanda & Shmee Well-Known Member

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    Feb 18, 2018
    Awh that is so very kind, I would not want to drive all that way for an MRI multiple times but we will see!
     
  12. sbluhrs

    sbluhrs Member

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    Jun 7, 2012
    TY so much for posting this. I have been in contact with Dr. McCue and I'm hoping that my Sophie will be able to have the surgery sometime in September. He's been away and won't be back until August 14th, so I hope to get this settled and set up at that point.

    So good to hear that they have a donor who is motivated to give them such a generous grant to perform this surgery on a number of cats. I know that Sophie would be a great candidate for it because she is still pretty young (between 5 & 6), and healthy except for this problem - at least I think she is. I live about 6 hours drive away from NYC, so this is much more doable than trekking to Washington State.
     
  13. Ana & Frosty (GA)

    Ana & Frosty (GA) Member

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    Jan 19, 2018
    Does your Kitty also have Cushing’s?

    I am still waiting for my IM vet to call me back so we can discuss the possibility of this surgery. Frosty had some vomiting again last night so I’m definitely concerned about his tolerance of Vetoryl.
     
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  14. Ana & Frosty (GA)

    Ana & Frosty (GA) Member

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    Jan 19, 2018
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  15. Rardito

    Rardito Member

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    Jul 20, 2018
  16. sbluhrs

    sbluhrs Member

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    Jun 7, 2012
    Nope, Sophie is definitely Acro, not cushings.

    Hoping you get Frosty's vomiting figured.
     

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