Miss Diagnosis: Cortisol Production Post BLA

Monday, April 23, 2012

Cortisol Production Post BLA

We are told that bilateral adrenalectomy is going to be "the cure" once and for all, and in most cases it truly is. But, I have been researching more on this subject sine Alex's recurrence. One of the articles I found click here states "Residual adrenocortical function have been demonstrated in 9/37(25%) after TBA for CD". At UCSF the endocrine department and tumor board told us "we don't know what normal cortisol levels are post BLA, no one ever checks". Their point being, people get better and there is no need to check for a hormone that should no longer be present.

Once again, I have a theory. Assuming that the vast majority (90% ?) of BLA patients had "florid" Cushing's (as opposed to cyclic) prior to BLA, then we could assume that any cortisol produced post BLA would be in a normal pattern as well. Based on this assumption, all it would take would be a decreased dose of steroid to solve any problem.

In the cyclic patient population we are seeing a higher number of patients experiencing problems with cortisol production post BLA. Here, my assumption would be that the naturally produced cortisol levels are again fluctuating like they were prior to BLA. With this cyclic production, cortisol supplements can not be accurately determined and once again patients find themselves in limbo.

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Transphenoidal Pituitary Surgery- From the UCSF web site

What happens during surgery?
The surgical removal of the pituitary adenoma is performed by a technique called a transsphenoidal operation. The word 'transsphenoidal' describes the path the surgeon follows to reach the pituitary gland. The word comes from 'trans', meaning 'to cross or pass through', and 'sphenoid', the name of the cavity (the sphenoid sinus) that is passed through to reach the pituitary gland. Newer techniques and improvements in technology now allow removal of these tumors without the need for an incision under the lip or within the nostril. The surgeon begins the approach by entering through the nostril on one side. The surgeon uses a brilliant fiber optic light to illuminate the internal anatomy, a microscope to magnify the area of surgery to 12 times the actual size, and very tiny microsurgical instruments especially designed for this particular operation. The surgeon guides the surgical instrument into the nasal cavity and an opening is made in the sphenoid bone. The sphenoid sinus is entered, and then an opening is made in the wall of the sella turcica to expose the pituitary gland. The adenoma can be readily distinguished from the normal pituitary gland tissue and is removed without removing the normal gland. After the surgeon removes all the tumor tissue, the small cavity that is left is treated with alcohol to destroy any tumor cells that may remain. This cavity is then sealed, sometimes with a piece of fat that the surgeon removes from the patient's abdomen. The surgeon then applies a biological 'glue' that helps seal the pituitary area from the nose and promotes natural healing. No nasal packs are used with this approach.