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These pictures were taken by Christy and MaryO April 5-8, 2006

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Note: These articles are provided in furtherance of the mission of Cushing's Help and Support to help people with Cushing's or other endocrine problems, their friends and families through research, education, support, and advocacy. These news items are intended to serve as background concerning its subject for patient-physician discussions and discussions among Cushing's Help and Support Message Board Members.

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Published June 13, 2006

MEDICAL Q& A »

Lack of key enzyme associated with development of rare tumor

June 12: Researchers at the National Institutes of Health have discovered that a rare tumor of the adrenal glands appears to result from a genetic deficiency of an important enzyme. The enzyme is one of a class of enzymes involved in halting a cell's response to hormones and appears to stop cells from dividing.

The study, published in Nature Genetics and released by EurekAlert was conducted by researchers in NIH's National Institute of Child Health and Human Development. The NIH group collaborated with scientists from the Mayo Clinic, the Cochin Institute in Paris, the University of Paris, Ohio State University in Columbus, and the Universitaire Vaudois in Lausanne, Switzerland, in collecting samples from patients with rare adrenal disorders. Scientists from Sapio Sciences in York, Pennsylvania, assisted in the analysis of the data.

In conducting the study, the researchers used gene arrays to analyze the DNA of patients with a rare tumor of the adrenal glands, known as micronodular adrenocortical hyperplasia, explained the study's senior author, Constantine Stratakis, M.D., D(Med)Sc, Chief of NICHD's Section on Endocrinology and Genetics. The researchers also used the technology to analyze samples of the patients' tumors.

The researchers found four patients who had mutant copies of a gene that contains the information for Phosphodiesterase 11A (PDE11A). Phosphodiesterases are a family of enzymes involved in "switching off" a cell's response to hormones, Dr. Stratakis explained.

For a hormone to affect the cell, it must first bind to a molecule, or receptor, on the cell's surface, analogous to how a key fits into a lock. This action triggers the cell to produce substances known as cyclic nucleotides. These function as "second messengers," often stimulating the cell to begin an activity. In the case of adrenal cells, cyclic nucleotides, such as cyclic AMP and cyclic GMP, may stimulate cell growth or other activities. Once the activity has ended, phosphodiesterases degrade the cyclic nucleotides, thereby halting the cell's response to the hormone.

In the study, the patients' tumors were made up of cells that were deficient in the enzyme PDE11A. This enzyme halts cyclic nucleotide production in adrenal cells as well as in other kinds of cells in the body. Because they lacked PDE11A, the patients' adrenal cells had higher levels of cyclic nucleotides. The researchers believe that these higher cyclic nucleotide levels led to the formation of tumors.

The gene for PDE11A contains the information needed to make 4 slightly different forms of the enzyme. The form of the enzyme that was mutated in the patients who took part in the study was found in large amounts in normal adrenal glands and in even larger amounts in normal prostate glands, Dr. Stratakis added. Other forms of PDE11A are found in several other tissues, including the testes, skeletal muscle, and the heart.

Dr. Stratakis noted that although the evidence associating the mutation in the gene for PDE11A to the development of adrenal tumors was very strong, the study was not capable of proving that the mutation actually caused the tumors. In their article, the researchers wrote that drugs used to treat erectile dysfunction interfere with the functioning of PDE11A. The researchers noted that PDE11A "is partially inhibited" by the drug tadalafil and "weakly" inhibited by sildenafil. They added that there are no reports in the medical literature of malfunctioning adrenal glands or increased adrenal cell growth in users of these drugs.

"However, detailed clinical studies addressing this potential complication are currently lacking," they wrote. Dr. Stratakis and his colleagues are currently planning studies to determine if differences in the gene for PDE11A might influence an individual's cancer risk.

Cleveland Clinic Reports Experience with Laparoscopic Radical Adrenalectomy

Written by Michael J. Metro, MD
Monday, 31 January 2005
BERKELEY, CA (UroToday Inc.) - Laparoscopic adrenalectomy has become the gold standard approach for benign surgical adrenal disorders such as aldosteronoma, Cushing's disease and pheochromocytoma. BERKELEY, CA (UroToday Inc.) - Laparoscopic adrenalectomy has become the gold standard approach for benign surgical adrenal disorders such as aldosteronoma, Cushing's disease and pheochromocytoma. However, laparoscopic adrenalectomy for solitary metastasis or primary adrenal cancer remains a matter of considerable debate. Adrenal cancer rightfully confers the possibility of carcinomatosis or port site metastasis, as noted in initial published case reports. Given the controversial nature of this topic, the group at Cleveland Clinic headed by Dr. Inderbir Gill reviewed their single center experience with laparoscopic adrenalectomies for malignancy. Their results are reported in the February, 2005 issue of the Journal of Urology.

Their cohort comprised 31 patients (33 adrenalectomies) with preoperative suspicion of a solitary metastasis to the adrenal gland, and those who were incidentally found to have primary adrenal malignancy. Selection criteria for the laparoscopic approach on pre-operative CT were an adrenal mass of 10 cm or less without evidence of peri-adrenal infiltration, caval thrombus or bulky locoregional adenopathy.

A closer look at the study population revealed a mean age of 59.8 years. Mean tumor size was 5 cm. The laparoscopic approach was transperitoneal in 17 cases, retroperitoneal in 15 and transthoracic in 1. Pathology reports indicated a diagnosis of adrenal metastasis in 26 patients; with the primary cancer being renal cell carcinoma (RCC) in 13 patients, colonic metastasis in 5, and lung metastasis in 4 patients. Six patients had primary adrenocortical carcinoma (ACC). Surgical margins of the adrenalectomy specimen were negative for cancer in 19 cases (56%), indeterminate in 2 (6%) and positive in 1 (3%). The pathology report made no mention of margin status in 11 patients (33%).

Analysis revealed a current median follow-up of 26 months. Overall, 15 patients (48%) died and 16 (52%) were alive. Of these 13 (42%) had no evidence of disease. Local recurrence was noted in 7 patients including 3 with metastatic RCC, 2 with metastatic colon cancer and 2 with primary ACC. Surgical margins had been positive in one patient with a local recurrence. One patient with bilateral metastatic adrenal masses from RCC developed carcinomatosis 7 months postoperatively. They noted no port site metastases. Survival was similar in patients with tumors less than 5 cm vs. 5 cm or greater. Survival was not associated with patient age, tumor size, operative time or surgical approach. Survival was compromised in patients who developed local recurrences, with a median survival of 17 months.

In conclusion, their study shows that laparoscopic radical adrenalectomy can be performed with acceptable outcomes in carefully selected patients with a small, organ confined, solitary adrenal metastasis or primary adrenal carcinoma. The results of this group from Cleveland Clinic compare favorably with a contemporary open series from Memorial Sloan Kettering Cancer Center.

J Urol. 2005 Feb; 173(2):519-25

Date Posted: Tuesday, June 13, 2006

PerkinElmer, Inc. has announced that its neonatal screening technology has been selected by State of Israel's Chaim Sheba Medical Center, Tel Aviv, to create a comprehensive newborn screening program that is intended to cover every child born in Israel.

Cortisol the chameleon

Hormone fights stress but can lead to dangerous belly fat

Connie Midey
The Arizona Republic
Jun. 13, 2006 12:00 AM

For all the research into cortisol's association with stress, belly fat and poor health, the substance remains a mystery to many people.

"It's not a simple hormone," says Malcolm Low, associate director of the Center for the Study of Weight Regulation at Oregon Health and Science University in Portland. "The issue is trying to sort out the things that are caused directly by too much of it."

Psychologist Marci Gluck, a National Institutes of Health researcher on assignment at Phoenix Indian Center, says studies have established a relationship between high cortisol and potentially dangerous abdominal fat.

"But we haven't really come up with a direct mechanism for how all of this is happening," she says. "If it were just as simple as reducing cortisol, I'm sure the pharmaceutical companies would have picked up on that already."What is cortisol?

Cortisol is a naturally occurring steroid hormone made by the adrenal glands, the triangular glands located on top of each kidney.

"It's an essential hormone for life," Low says. "It acts on virtually every cell in the body."

Levels rise and fall in 24-hour cycles, usually reaching highs from 6 to 8 a.m. and lows about midnight.

But like the adrenaline also secreted by the adrenal glands, cortisol production increases with the body's "fight or flight" response to stressful situations, whether physical or emotional.

How cortisol protects us

Cortisol in healthy amounts helps the body respond to stress, produce energy, regulate heart functions, normalize blood sugar and fight inflammation. Delivered in occasional short bursts, it can increase odds for survival, heighten memory and lower sensitivity to pain.

Synthetic forms, known as hydrocortisone, are used in oral, topical and injected forms to fight allergic reactions and inflammation.

How cortisol can harm us

When chronic stress keeps cortisol levels persistently high, the hormone "switches from being a protector to being a very toxic substance," says Larry Woodruff, senior lecturer in the exercise and wellness department at Arizona State University Polytechnic in Mesa.

It can destroy tissues throughout the body, slow healing and impair memory, and it plays a role in the development of abdominal fat, which has been associated with heart disease and insulin resistance.

What studies are finding

While working in New York, Gluck studied the effects of stress on people with binge-eating disorder. Statistically, they had "nearly significant" higher cortisol levels than the control group after being subjected to stress and were significantly hungrier in the following hour.

(After controlling for insulin levels, the binge eaters' cortisol levels were "significantly" higher.)

A University of California-San Francisco researcher found that healthy, lean women who produced high levels of cortisol in response to stress ate more sweet, high-fat foods when left alone in a room afterward with a basket of snacks, Gluck says.

Low says laboratory mice given a form of cortisol at low levels start eating more.

"It seems to have a permissive, stimulatory effect on their appetite," he says. "But you can't treat that problem by getting rid of the cortisol. You need it for other functions."

Although Low says cortisol research doesn't necessarily prove a cause-and-effect relationship, the hormone's role in other areas of health also is being examined.

In a pilot study, Stanford University researchers measured irregular cortisol levels in Alzheimer's caregivers that put them at risk for heart disease and some cancers.

And an NIH study of monkeys that responded to stress in infancy with high cortisol concentrations found they were more likely to drink alcohol as adults than low-cortisol responders.

'Blocking' supplements

Dietary supplements that claim to aid weight loss and prevent disease by controlling production of cortisol have been criticized as ineffective by the non-profit Center for Science in the Public Interest and the Federal Trade Commission.

"Most of these supplements contain vitamins and natural plant extracts," Low says. "It's pretty much unproven that any of them would have any effect on cortisol."

And even if they did, the supplements wouldn't cause significant weight loss, he says. Most people put on extra weight because they eat too much and exercise too little, not because they have too much cortisol.

Modifying levels naturally

Anything that relieves stress - yoga, reading, music, journaling, a nap - can help lower cortisol levels, Low and Gluck say.

Woodruff says regular exercise will, over time, moderate the adrenaline and cortisol response to stress.

As a result, he says, "the physiological response of an aerobically fit person to stress will be less intense and harmful than that of an unfit person perceiving the same general level of stress."

Gluck suggests preparing for situations that usually lead to stress eating.

"Instead of M&Ms, have healthy foods in your kitchen or workplace," she says. "Most people say, 'I'm not going to do it this time,' but that can be very unrealistic. It's much better to prepare, just in case."

Reach the reporter at connie.midey@arizonarepublic.com or (602) 444-8120.

(HealthDay News) -- Cushing's syndrome affects as many as 15 million people each year, typically between the ages of 20 and 50. It occurs when the body's tissues have been exposed for an extended period to too much of a hormone called cortisol.

According to the U.S. Endocrine and Metabolic Diseases Information Service, people with Cushing's often gain weight in the upper body, and have an abundance of fat around the neck, a round face, and thin arms and legs. Cushing's also leads to weakened bones and thin skin, which may bruise easily.

Treatment options include surgery, radiation, chemotherapy or a medication regimen that prevents production of cortisol, the NIDDK says. If medications taken for other conditions are causing Cushing's, your doctor may adjust the dosage to control both problems.

Portland, Oregon - A doctor didn't advise Vermont's Karen Nolan*** (Rooon on the boards) that she might be one of the scant 3.5 per million people diagnosed annually with Cushing's disease - another Cushing's patient did. After reading Nolan's post on an Internet message board, another patient suggested Nolan's lab results and symptoms could indicate pituitary disease and that help might be found more that 3,000 miles away at Oregon Health & Science University.

"She sent me a link to the Cushing's Help and Support Web site (www.cushings-help.com) a patient-created and maintained site, and suggested an Oregon doctor known for solving difficult cases," said Nolan. That doctor is William Ludlam, M.D., Ph.D., director of the OHSU Pituitary Unit, one of the largest neuroendocrine centers in the country.

Cushing's disease is a form of Cushing's syndrome and is caused by a tumor in the brain's pituitary gland that secretes excess levels of a hormone called ACTH. Elevated ACTH in turn stimulates the adrenal glands to produce excess cortisol, wreaking havoc on the body. Symptoms of the disease include: uncontrolled obesity, rounded face, increased fat around the neck, and fragile skin that bruises easily and heals poorly. The bones are weakened, and routine activities such as bending, lifting or rising from a chair may lead to backaches, rib and spinal column fractures.

"Cushing's tumors are almost always benign. However, they can be devastating to a patient's health and quality of life. They can even be fatal without proper treatment," said Ludlam, a professor of medicine (endocrinology, diabetes and clinical nutrition) in the OHSU School of Medicine. "The Internet is changing the face of rare diseases like Cushing's. Patients tell me they simply "Googled" their symptoms and there it was."

Cushing's can be difficult to diagnose. Many patients who contact Ludlam first test positive for the disease but subsequent test results are negative. In addition, because the disease is relatively rare, all physicians do not necessarily have the expertise to effectively identify the disease. In fact, many patients are repeatedly told they are not even sick and that the problem can be solved simply through diet and exercise.

"Many times with Cushing's, only the most textbook cases are readily diagnosed," explained Ludlam. "However, even these patients, who display the physical signs of the disease and have consistently positive tests often go undiagnosed for years. But there is also a large pool of people with Cushing's completely below the radar of most clinicians. They might not have the physical symptoms or possibly their biochemistry isn't consistently positive, but they still have it."

These two photos taken a few years apart of Cushing's patient Lisa Eldridge demonstrate the tremendous impact the disease can have on a person's body weight.

"When my primary care physician suspected Cushing's, he sent me for evaluation," said Lisa Eldridge ***, who is now Nolan's support group friend. "After having both positive and negative tests for Cushing's and an unusual thyroid finding, I was told I had Graves Hyperthyroidism, a disease known for making a person rail thin. However, I was gaining weight uncontrollably. After consulting the Internet, I was even less convinced my problem was thyroid in nature. If I had Cushing's, I knew it was intermittent. At this point I'd lost eight years of my life."

Historically, according to Dr. Ludlam, Cushing's patients are sick on average five to 10 years before diagnosis.

Eldridge's continued research led her to realize that she needed a specialist who recognized the disease could be intermittent while utilizing a conservative, yet aggressive testing protocol. Having an experienced pituitary neurosurgeon on the team who handled 50 or more cases a year was also a must.

"The one thing I was sure about after all my research was my choice in Dr. Ludlam and the OHSU team. Whether he told me I did or didn't have Cushing's, I knew his was an opinion I could trust."

Both Nolan and Eldridge met Jaimie Augustine*** on Cushing's Help and Support. The Three Musketeers, as they call themselves, instantly bonded last year after finally meeting in person at OHSU. Augustine, a California native, even refers to Karen as her Cushie Mama. At 22, Augustine already has had two pituitary surgeries aimed at combating the disease.

"According to an old Irish proverb: 'It's better to laugh than to cry,'" says Augustine, "We laugh over everything, especially our wildly fluctuating weight gain. Nothing's sacred. It's the only way to get through this."

Nolan is the group's entertainment director during trips to OHSU.

"Whenever we fly out to Portland, there's always a Cushie party in the works," said Nolan, "We bring the "Testers," the "Pre-ops" and the "Alumni" returning for post-op testing together. And of course we always enjoy seeing our local Cushies from Oregon and Washington State". Eldridge, who grew up in Maine muses, "Oregonians are like Mainers-very warm and friendly. Traveling to Portland is like going home."

For more information on OHSU, go to http://www.ohsu.edu/


*** Message Board Members

Health & Medicine Week - Jun. 08, 2006

2006 JUN 8 - (NewsRx.com) -- Reports from University of Padua describe recent advances.

This trend article about University of Padua is an immediate alert from NewsRx to identify developing directions of research.

Study 1: According to recent research from Italy, recombinant human growth hormone (GH) affects metabolic parameters and preclinical atherosclerotic markers in hypopituitary patients with growth hormone deficiency.

"This study examines the effects of growth hormone replacement on body composition, insulin sensitivity, lipid profile, endothelial dysfunction and carotid intima media thickness in patients with adult-onset growth-hormone (GH) deficiency," wrote S. Benedini and colleagues, University of Padua.

They ...

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Most memoirists face the challenge of showing why their story is worth reading; after all, who doesn't have crazy families, inspiring teachers or midlife crises? Authors of medical memoirs, however, face the converse. Since their experiences are inherently dramatic and exotic to most readers, plot can overwhelm content. Such books can devolve into a shooting script for "ER."

Thankfully, Katrina Firlik's new memoir, "Another Day in the Frontal Lobe," walks that fine line between navel-gazing and melodrama to provide a thoroughly entertaining and candid look at the rarefied world of modern neurosurgery.

"The brain is soft," she begins. "Some of my colleagues compare it to toothpaste, but that's not quite right. It doesn't spread like toothpaste."

Nambirajan T., Jeschke S., Leeb K., Janetschek G.

Elisabethinen Hospital, Department of Urology, Linz, Austria

INTRODUCTION & OBJECTIVES: Patients with hereditary form of phaeochromocytoma develop multiple tumours at young age and are prone for recurrences. Laparoscopic partial adrenalectomy removes the tumour, preserving the adrenal cortical function and avoiding hormonal replacement therapy. It is feasible to perform second adrenal sparing surgery laparoscopically for recurrences, which is illustrated with these 5 cases.

MATERIAL & METHODS:

RESULTS: Laparoscopic partial adrenalectomy was feasible in all but one patient despite previous surgery. There was no need for conversion to open surgery. There were no intra or postoperative complications. Histology confirmed phaeochromocytoma in all patients and there were no malignancies. At follow-up, blood pressure and urine catecholamines were within normal levels in all patients except one (no 5), who has asymptomatic elevation with a recurrent tumour on the contra lateral side. He is under surveillance. The patient 3 was pregnant at 20 weeks of gestation and she completed pregnancy with a full term baby. None of the patients required steroid replacement.

CONCLUSIONS: Laparoscopic partial adrenalectomy is feasible after previous explorations and is technically easier if the previous approach had been laparoscopic as well. Laparoscopy is the ideal approach in patients prone for recurrent tumours.

TRANSPERITONEAL LAPAROSCOPIC ADRENALECTOMY: LESSON LEARNED FROM MORE THAN 200 CONSECUTIVE CASES

Cestari A., Guazzoni G., Centemero A., Riva M., Zanoni M., Naspro R., Bellinzoni P., Rigatti P.

Vita-Salute, San Raffaele Hospital - Ville Turro, Urology, Milan, Italy

INTRODUCTION & OBJECTIVES: Laparoscopic adrenalectomy is considered the treatment of choice for the surgical ablation of most benign adrenal lesions. Several approaches and several surgical techniques have been described. We present our 12-year experience in laparoscopic transperitoneal adrenal surgery.

MATERIAL & METHODS: Between October 1992 and September 2003, 231 laparoscopic approaches to the adrenal gland have been performed, namely 185 unilateral adrenalectomy (79 right, 106 left, 65 Conn's disease, 42 Cushing's disease, 37 Phaeochromocytoma, 32 non functioning adenomas and 9 malignancy), 19 bilateral adrenalectomy and 8 cases of conservative surgery. The patients were placed in a 60- degree flank position with the bed flexed to increase the surgical field; the first step of the intervention was the early ligation of the adrenal vein, as a land mark to correctly dissect the adrenal gland.

RESULTS: The laparoscopic procedure was successfully completed in all but 5 cases which were converted into open surgery (1 for duodenal injury during pneumoperitoneum induction with open access and 2 during procedures for malignancy). Mean operative time was 152 min. in the unilateral group, 235 min in the bilateral group and 84 min in the conservative group. Delayed complications included 3 cases of hem peritoneum which were drained surgically, 3 cases of severe blood loss which were treated with blood transfusions, 2 cases of wound infection. Patients were able to ambulate on the morning of the first postoperative day and were discharged respectively 2.7, 5 and 1.5 days after surgery in the unilateral, bilateral and conservative group.

CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy is a safe and effective, minimally invasive approach for patients with benign functioning or non functioning adrenal masses. This technique has low morbidity, minimal postoperative analgesic requirements, short hospital stay.

LAPAROSCOPIC ADRENALECTOMY FOR LARGE TUMOURS (5-10CM)

Droupy S.¹, Hammoudi Y.¹, Eschwège P.¹, Young J.², Giuliano F.², Benoit G.¹

¹CHU de Bicêtre, Department of Urology, Le Kremlin Bicêtre, France, ²CHU de Bicêtre, Department of Endocrinology, Le Kremlin Bicêtre, France

INTRODUCTION & OBJECTIVES: Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland. The limits of laparoscopy have not been defined and evolve with surgeons experience. We reviewed our experience with laparoscopic treatment of adrenal tumours from 5 to 10 cm diameter in order to determine feasibility and carcinological safety.

MATERIAL & METHODS: From 1997 to 2002, 56 laparoscopic adrenalectomy were performed by one surgeon. 6 bilateral, 34 for adrenal tumour less than 5 cm and 10 for tumours from 5 to 10 cm. The first 21 were performed using the retroperitoneal laparoscopic approach and the 35 last using a transperitoneal laparoscopic approach. Causes of discover were ultrasonography for abdominal pain (4), Cushing disease (2), a CT scan for breast cancer (2), flank pains (1) and hypertension (1). Patients were 7 women and 3 men, from 28 to 82 years of age.

RESULTS: All the tumours were removed by laparoscopy: the first one using the retroperitoneal approach and 9 using the transperitoneal approach as handling of the tumour was difficult in the confined retroperitoneal space.

Mean operative time was 155 min. (90-215). No preoperative complication occurred. Postoperative complications were one pleural effusion and one haematoma on a trocar site needing two days more of hospital stay. Mean hospital stay was 4.1 days (3-6). Pathological examination showed 3 adrenocortical carcinomas, 2 adenomas (Weiss 1), 2 cavernous lymphangiomas, one leiomyosarcoma, one myolipoma and one adenomatoide tumour. Mean follow-up was 29 months (7 to 60). One patient with a metastatic adrenocortical carcinoma at the time of surgery progressed under OP’DDD. Two patients with adrenocortical carcinomas are free of disease after 60 and 48 months.

CONCLUSIONS: Laparoscopic removal of adrenal tumours more than 5 cm is feasible and carcinologically safe. Tumours are carcinomas or rare tumours for which radical adrenalectomy is required. The transperitoneal laparoscopic approach seems to be more appropriate for large tumours.

ADRENAL METASTASES OF UNKNOWN PRIMARY MALIGNANCY - WHAT IS THE DIAGNOSTIC WAY?

Wunderlich H.¹, Reichelt O.¹, Hindermann W.², Kosmehl H.³, Schubert J.¹

¹Friedrich-Schiller-University, Department of Urology, Jena, Germany, ²Friedrich- Schiller-University, Department of Pathology, Jena, Germany, ³Helios-Clinic, Department of Pathology, Erfurt, Germany

INTRODUCTION & OBJECTIVES: The approach to incidental adrenal masses depends on whether the patient is known to have a primary malignancy. Adrenal glands are frequently involved in metastatic disease. The extent of diagnostic imaging in metastatic findings has been reconsidered, in view of the detection of the primary tumour.

MATERIAL & METHODS: In a series of 14.793 autopsies from 1985 till 1995 323 adrenal metastases were revealed. More than half (68,2%) of all adrenal tumours were metastases, of which more than 40% were bilateral.

RESULTS: Most of the metastatic tumours were carcinoma (306/323 metastases), sarcoma (8/323 metastases), malignant melanoma (5/323 metastases) and malignant lymphomas (4/323 metastases). Metastatic disease from lung carcinoma was seen in 195 out of 323 adrenal metastases. Adenocarcinoma and small cell carcinoma were the most common subtype. The second and third most common sites were breast cancer and colorectal cancer in female patients and renal cell carcinoma and colorectal as well as pancreas carcinoma in male patients. Urological carcinomas have shown a low frequency of adrenal metastases, except of renal cell carcinoma. Adrenal metastases in prostate cancer were seen in 5 out of 229 cases, in transitional cell carcinoma of the urinary bladder in 3 out of 125 patients and in transitional cell carcinoma of the renal pelvic in 2 out of 17 cases. In malignant tumours of the testes (n=36) and the penis (n=4) no adrenal metastases were found.

CONCLUSIONS: As soon as adrenal metastasis is suspected without knowing the primary tumour diagnostic work-up needs to be focused on kidney, liver, spleen, GIsystem, breast and especially on lung. Adrenal exploration has to be considered as long as no primary tumour is diagnosed.

If she could do it, anyone can.

So says Donita Montgomery, 29, a local teacher who lost 87 pounds and feels unstoppable - especially when she's kickboxing.

At 5 feet 7 inches, she now weighs 145. It wasn't that long ago, however, that she was 202 pounds and wearing a size 22.

Montgomery, now a size 9, recalls that her most recent weight gain came in 2002. Her sedentary lifestyle and job as a fifth-grade teacher made it easy to pile on the pounds because she spent most of the day sitting. "You pretty much just stay in one place and teach. There's not a lot of movement," she said. In addition, irresistible yet fattening treats were always available at staff meetings and training sessions. Two years ago, her life changed. Her sister joined Naturally Women on Tucson's East Side (now Darla's Fitness for Women) and nagged her to join. In January 2004, she did, and has gone six days a week ever since. "It was sort of a New Year's Resolution. I didn't like the way I looked anymore, and my daughter at that time was a year and a half, and I couldn't play with her," Montgomery said. With determination, a caring health club staff and a personal trainer, she lost the weight at a rate of 1 to 2 pounds a week. "I think the fact that I took it slow helped," Montgomery said. She didn't have unrealistic expectations. She wasn't looking for a quick fix. She wanted a lifestyle change. She cut her diet to 1,200 calories per day, but allowed herself one "bad day" each week, on Saturdays, to indulge in chocolate or junk food. As time went on, the treat days became less important. Montgomery won't lie. "It was definitely hard to stick to it," she said. At first, she could only do 15 minutes on the treadmill. "I just didn't have enough energy to go longer." But each week she did a little more. She plugged along, and kept a food journal to hold herself accountable. Today, she sticks to the same 1,200-calorie diet and exercises daily. "I go straight from picking up my daughter (at day care) to the gym." Her biggest challenge then was finding time to exercise. "I couldn't go before work because they didn't have the day care open, and after work it was hard because I'd get home after 7 p.m., but I needed to do it. I needed to make a difference for myself. I need to put myself first." Another challenge for Montgomery was exercising despite a brain tumor: pituitary adenoma. The tumor caused her body to simulate pregnancy and menopause at the same time, she said. "So the harder I worked out, the more my body thought I was starving a baby and it would store fat," she said. The tumor was removed in 1997 and two more grew, so she's on medication for those, she said. "It's harder to work out," she said, but worth the payoff. Exercising "gave me more energy for everything" and "I was a much nicer person." It relieved her job stress so she could arrive home to her family happier and more energetic. "I don't think it's selfish to put yourself first, because if not, you start to resent everybody. To be happy you need to be first sometimes." Her best moments are when former students fail to recognize her. "One kid said, 'You don't even look like the same person,' " Montgomery said. Then with a hint of pride in her voice, she added, "And I don't."

POSTED: 6:47 pm EDT May 23, 2006

PHILADELPHIA -- Physicians at Thomas Jefferson University Hospital performed brain surgery Tuesday using some of the newest technology around.

The doctors removed a tumor from a patient without making an external incision in his head or face. They removed a pituitary tumor through the patient's nose.

Instead of the traditional, more invasive surgery, which requires opening up the brain and skull, Dr. Marc Rosen and Dr. James Evans performed minimally invasive surgery.

The doctors used an endoscope to visualize and then remove a pituitary microadenoma. With the new low-risk procedure, surgeons can operate on benign and cancerous tumors in patients who previously might not have been considered candidates for surgery.

Patients can also begin radiation and chemotherapy sooner than if they had open surgery.

Usually, these pituitary tumors have no symptoms, but when they do, people can have headaches, decreased energy, lowered sex drive or weight gain -- symptoms sometimes thought to be linked to aging.

The operation was broadcast live on the Internet. If you would like to see a video of the operation, Click here.

Copyright 2006 by NBC10.com. All rights reserved.

Risperdal May Cause 70 Percent Of Pituitary Tumors.

May 31, 2006 3:00 a.m. EST

Yvonne Lee - All Headline News Staff Reporter

Washington, D.C. (AHN) - A new study suggests Risperdal may be linked to 70 percent of pituitary tumors.

The Food and Drug Administration worked in conjunction with Duke University on the study, which found the antipsychotic and similar medications may cause pituitary tumors.

The researchers caution the study's findings suggest, rather than prove, a link.

Healthday News reports Risperdal is the most commonly-prescribed medication among atypical antipsychotics. These are used to treat schizophrenia, paranoia, and manic-depressive disorders.

Study co-author Dr. P. Murali Doraiswamy, a psychiatrist at Duke University Medical Center, says, "Atypical antipsychotics are lifesaving medications for a lot of people. By no means are we advocating that people stop using them, especially risperidone."

The findings appear in the June 2 issue of Pharmacotherapy.