Medical therapies for ACTH-producing tumors: What's the verdict?

In this article, the authors look at possible medical therapies to treat ACTH-producing tumors including those which cause Cushing's Disease (CD) and silent corticotroph adenoma (SCA). CD is caused by an ACTH producing pititary adenoma. SCA shows the same immunoreactivity of a pituitary adenoma without the same signs or symptoms of Cushing's. The authors take great pains to discuss and define the pathology of each of these.

This study examined the effect of somatostatin receptor (SSTR) subtype (1-5) and dopamine receptor type 2 (D2R) on CD, SCA, and non-functioning pituitary tumors (NFT). It is a meaty report with fairly detailed data for those who are interested and admits some limitations with differnt gene profiles of various pituitary tumors.

The advance publication text is free. In short, the authors concluded:

...the increased expression of SSTR5 in ACTH-secreting pituitary tumors causing overt CD and increased expression of SSTR1 and 2 in SCA...suggest that
somatostatin analogs more selective for SSTR5 and SSTR1 and/or 2 could be used
as an effective drug for medical treatment for CD and SCA, respectively, whereas
the clinical application of dopamine agonists selective for DR2 is very limited
in CD or SCA.

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Toru TATENO, Masako KATO, Yuji TANI, Kenichi OYAMA, Shozo YAMADA and Yukio HIRATA (2009). Differential Expression of Somatostatin and Dopamine Receptor Subtype Genes in Adrenocorticotropin (ACTH)-Secreting Pituitary Tumors and Silent Corticotroph Adenomas Endocrine JournalDOI: 10.1507/endocrj.K08E-186

Diagnosing and Treating Cushing's: Presentations by Dr. Theodore C. (Ted) Friedman

Dr. Friedman's original PowerPoints may be found at his website. These are very informative and easy to follow.

Publish at Scribd or explore others: Health & Medicine Research tumor adrenal

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Publish at Scribd or explore others: Research tumor adrenal

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Publish at Scribd or explore others: Research tumor adrenal

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Publish at Scribd or explore others: Research tumor adrenal

CT imaging in the hunt for ectopic ACTH tumors

Once the biochemical evidence of excess ACTH production leads to the diagnosis of Cushing's Syndrome for a patient, the next step is determining the source of excess ACTH production. Usually the source for the excess ACTH is a tumor on the pituitary gland. However, ectopic sources may also be ACTH secreting tumors.

Eighty to 85% of Cushing’s syndrome is ACTH-dependent, of which 80–90% will be due to a pituitary adenoma—Cushing’s disease (CD) [1]. Ten to 15% will have a nonpituitary source, referred to as ectopic ACTH secretion (EAS) [2], of which 80% have an identified source within the chest and abdomen whilst 20% have no detected source and are referred to as occult [1].

This article talks about the use of computed tomography (CT) to locate the source of the EAS. According to the authors, a bilateral inferior petrosal venous sampling (BIPPS) is the first step in determining whether the source of excess ACTH is ectopic, with a 95% sensitivity. They say "false positives are extremely rare (<1%)> and there is a false negative rate of 2–4%".

The authors include information about imaging multiple tumors including the following:

Bronchial carcinoids

Thymic carcinoids

Gastrointestinal carcinoids

Pancreatic neuroendocrine tumours

Medullary thyroid carcinomas

Phaeochromocytomas

They also mention other tumors briefly:

Many tumours have been reported in the literature to result in EAS such asovarian carcinoid, ovarian adenocarcinoma, ovarian androblastoma, ovarian teratoma, ovarian Sertoli cell carcinoma, ovarian dermoid cyst, prostatic adenocarcinoma, prostatic small cell carcinoma, small cell carcinoma of the uterine cervix and olfactory neuroblastoma [6].

The authors recommend the use of ¹¹¹In-octreotide in some cases and mention the enlargement of the adrenals, as well as shape and hyperplasia depending on the type of EAS. They conclude that CT imaging can lead to earlier diagnosis and treatment of these excess ACTH sources.

(Picture is from the article)

Paul A. Sookur, Anju Sahdev, Andrea G. Rockall, Andrea M. Isidori, John P. Monson, Ashley B. Grossman, Rodney H. Reznek (2009). Imaging in covert ectopic ACTH secretion: a CT pictorial review European Radiology DOI: 10.1007/s00330-008-1274-5

Current Treatment Strategies in Managing Aggressive Pituitary Tumors

Michael Buchfelder pulls together recent studies with a good synopsis of current treatments for aggressive pituitary tumors in this article. However, he doesn't address ACTH-producing adenomas which cause Cushing's Disease. He does, however, talk about some of the treatments that are being used for other types of tumors.

Buchfelder discusses the use of dopamine agents to control prolactinomas, and focuses on cabergoline and bromocriptine. Cabergoline is the preferred agent due to its ability to normalize prolactin levels as well as shrink tumor size with few side effects.

In the article, surgery is always the front-line approach for other tumors with secondary treatments to control recurrence and/or regrowth. Transsphenoidal endoscopic surgery is the first-line approach, but he does say surgical techniques can remove the bulk of the tumor "but do nothing to reduce the recurrence of aggressive tumors."

The somatostatin analogs (SSAs) lanreotide and octreotide are mentioned as effective agents for "other kinds of tumors", but only treatment of those causing acromegaly are described in depth.

SSAs can be used as primary therapy, pre-operatively to reduce the tumor volume
and make it more amenable to surgical removal, or post-surgery to control
re-expansion.

He also mentions the recent studies using the chemotherapy agent, temozolomide (another research blog I did recently), to control aggressive pituitary tumors.

Radiotherapy is a non-pharmacological treatment outlined in the article, with stereotactic radiation is only working for small tumors with the "precise location" known. Any type of radiotherapy works best in conjunction with surgical intervention.

He really articulates well the frustrations and complications with treating pituitary tumors with his closing remarks:

...we should not be reticent about using all options available (even in a single patient if necessary) to get the best possible control of symptoms.

Michael Buchfelder (2008). Management of aggressive pituitary adenomas: current treatment strategies Pituitary DOI: 10.1007/s11102-008-0153-z

There is more research on future treatment strategies which I hope to share in the next few days.

To learn more:

Is Temozolomide a new treatment for aggressive pituitary tumors?

A novel pituitary tumor transforming gene identified

A Cushie Champion: Dr. Ian McCutcheon (MD Anderson) (talks about tumors and treatments)

Recent Advances in Neuroendocrine Imaging Lead to Improved Diagnosis

Is Temozolomide a new treatment for aggressive pituitary tumors?

The authors of this study, Low 0⁶-methylguanine-DNA methyltransferase[P1] (MGMT) expression and response to temozolomide in aggressive pituitary tumours, detail the use of temozolomide as a possible treatment for the aformentioned tumors. They also evaluate 0⁶-methylguanine-DNA methyltransferase (MGMT) "expression in pituitary tumours and consider whether MGMT expression is associated with response to temozolomide therapy in aggressive pituitary tumours".

Why is this relevant? Because so many ACTH-secreting adenomas of the pituitary invade other structures. The study states:

Clinically significant pituitary tumours occur in approximately 1 in every 1000
individuals ...between 35-55% of adenomas demonstrate invasion into bone,
dura or adjacent structures such as the cavernous or sphenoid sinuses or
brain...

According to this article, some tumors display aggressive behavior and are resistant to current treatments. They can require the patient to have multiple operations and/or radiation therapy in order to control the growth.

Temozolomide works for some patients in the control of their tumors. Widely used for other brain tumors, its success has been mixed when applied to aggressive pituitary tumors. In this study, the relationship of "MGMT immunohistochemistry in two patients with aggressive pituitary tumours treated with temozolomide" is important. "[L]ow expression was demonstrated in a patient who responded to temozolomide whereas high expression was seen in another patient with no response to this agent 20."

When enlarging their study to 88 tissue samples from previous patients, the authors found their "work suggests that low MGMT protein expression, as assessed by immunohistochemistry, may be associated with a clinical response to temozolomide in aggressive pituitary tumours and supports the brief report of Kovacs et al."

The bottom line: MGMT immunohistochemistry is a promising technique for predicting the applicability of temozolomide for controlling aggressive pituitary tumors.


Ann I. McCormack, Kerrie L. McDonald, Anthony J. Gill, Susan J. Clark, Morton G. Burt, Kirsten A. Campbell, Wilton J. Braund, Nicholas S. Little, Raymond J. Cook, Ashley B. Grossman, Bruce G. Robinson, Roderick J. Clifton-Bligh (2008). Low 0(6)-methylguanine-DNA methyltransferase (MGMT) expression and response to temozolomide in aggressive pituitary tumours
Clinical Endocrinology DOI: 10.1111/j.1365-2265.2008.03487.x

Adrenalectomy improves quality of life for Cushing's patients although it may take years

Although adrenalectomies are only a first-line treatment for those with ACTH-independent tumors in Cushing's Syndrome (ectopic and adrenal tumors, benign and malignant), they are also often a treatment for those with Cushing's Disease when pituitary surgery fails to totally remove the source of excess ACTH.

Hypercortisolemia, the result of excess ACTH from the pituitary or from overproduction in ectopic or adrenal tumors, is very debilitating for those who suffer from CS/CD. According to the authors, "Untreated Cushing’s syndrome can cause significant physical and mental morbidity and mortality, with a mortality rate in untreated that is 4 times greater than the baseline population."

This study looked at the outcomes of 60 patients who underwent either a unilateral (53%) or bilateral adrenalectomy (47%) to treat their Cushing's. Except for one patient, all adrenalectomies were done laproscopically. The median follow-up time was 41.4 months. At that median time, 9 patients had died. 4 patients had died from the progression of malignant disease, 2 from unknown causes, 1 from pulmonary embolus 2 months after surgery, and 2 five months post-op from severe complications due to pituitary (ACTH-dependent) Cushing's Disease.

Around 75% of the common physical signs/symptoms of Cushing's resolved after surgery, but the central obesity only had a resolution rate of 57%. Diabetes was cured in 79%, hypertension "improved dramatically or was cured in 67%."

Symptoms took anywhere from a few weeks to 4 years to resolve with most of the physical changes resolving in a mean of 7-9 months. There was a great variability with no good predictor of this variability.

The remark that I find so telling is this:

In fact, we had several patients with ‘‘subclinical’’ Cushing’s who took over 2 years for their symptoms to resolve.

Too often those of us who suffer with Cushing's are told to wait until the disease "gets worse" before being diagnosed/treated.

The authors point out the complication rates which are typically higher for Cushing's patients than for others who undergo adrenalectomies for whatever reason. Immunosuppression leads to greater risk of infection. Addisonian crisis is another prevalent complication. However, overall they conclude that adrenalectomies are a safe and effective treatment option, but both physicians and patients must not expect overnight improvements. This is another case of where slow and steady wins the race.



R SIPPEL, D ELARAJ, E KEBEBEW, S LINDSAY, J TYRRELL, Q DUH (2008). Waiting for change: Symptom resolution after adrenalectomy for Cushing's syndrome Surgery, 144 (6), 1054-1061 DOI: 10.1016/j.surg.2008.08.024

New technology for the removal of pituitary and brain tumors

According to Advocate Lutheran General Hospital, "[t]he intra-operative Magnetic Resonance Imaging (MRI) system improves the accuracy of brain surgery for children and adults by providing real-time, high-quality images of the brain before, during and after surgery." Due to the shift of the brain and other structures during surgery, the tumor may not be exactly where the pre-surgical MRI showed it. This technology allows the surgeons to check during and post-surgery for accurate and adequate removal of a tumor.

Cushing's patients are notorious for having hard-to-find-and-remove pituitary tumors. Factor in hyperplasia and extension into the adjacent sella and sinus areas, and the problem is magnified. This technology is helping surgeons remove pituitary tumors with a better outcome because surgeons can view detailed, three-dimensional images of the brain in real time during an operation .

The video below tells about one patient's story.




To read more:

Medtronic
Advocate Lutheran General Hospital
University of California, Irvine

Mom was right, as always.....

When Kevin started growing out but quit growing up, his mother knew something was not right, even when Kevin's doctor said, "...you and your husband are big people. He’s just big."

Steven Waguespack, M.D., associate professor in M. D. Anderson’s Department of Endocrine Neoplasia and Hormonal Disorders [said], “Kevin had gained about 30 pounds in a year, but he had not grown any taller, which is very concerning for an underlying endocrine problem in children...Weight gain around the middle is a classic symptom in adults, but in kids the weight gain is often distributed all over the body. That’s how it was with Kevin. However, he didn’t have some of the other classic symptoms of Cushing’s like muscle weakness, stretch marks or skin thinning.”

The type of tumor on Kevin’s pituitary was unusual as well. While most Cushing’s tumors are very small, often not visible even on an MRI, Waguespack says Kevin’s was large.

“Kevin is proof that every case of Cushing’s doesn’t always have classic symptoms,” Waguespack says.

Kevin's tumor was removed by Dr. Ian McCutcheon of M.D. Anderson within a few weeks. A year later, Kevin has lost 18 pounds and grown 3 inches in height.

To read more:
Cancer News and Information - CancerWise - Cushing’s Disease Causes Abnormal Growth

Fiona Apple may just have it right....

He said 'It's all in your head' and I said 'So's everything' but he didn't get it --Fiona Apple in "Paperbag".

Pituitary tumors have a large spectrum pathology. These "little buggers" may cause large problems, also. Dr. Shereen Ezzat of the Toronto Cancer Institute has been studying pituitary tumors for several years, and presents the case for epigenetic disruption of gene expression which causes alterations of normal pituitary cells. Using the information he and others have gathered, he is hopeful treatments for these lesions/tumors can be developed. Since the morbidity/mortality of most with pituitary tumors is greatly increased, and the only long-term therapies so far are surgical or radioactive, improved treatment is anxiously sought by those of us with Cushing's or presently in remission.

According to Dr. Ezzat, pituitary tumors comprise 10% of the tumors surgically removed intercranially with increased morbidity due to invasion of surrounding structures. As a Cushie community, we know this only too well first-hand. All too often the only recourse for the hypercortisolemia due to ACTH producing tumor cells is a bilateral adrenalectomy. Radiation is often a secondary treatment to decrease tumor growth or Nelson's syndrome.

In another article, Dr. Ezzat says, "Some pituitary adenomas grow rapidly, producing symptoms of an intracranial mass, loss of normal anterior pituitary hormone production, and visual-field disturbances due to stretching of the overlying optic chiasm. They can invade downward into paranasal sinuses, laterally into the cavernous sinuses (thereby disrupting coordinated eye movement) and upwards into the brain. They can cause death by invasion of the brain."

But size does NOT always matter with these tumors. Dr. Ezzat also says "they can cause mood disorders, sexual dysfunction, infertility, obesity and disfigurement, hypertension, diabetes mellitus and accelerated heart disease. If untreated, hormone-excess syndromes can be lethal."

In the pre-print, recent article, Epigenetic Control in Pituitary Tumors , Dr. Ezzat discusses epigenetically-mediated gene dysregulation as a cause for the production of pituitary tumors. He explores the role of fibroblast growth factors and histone gene silencing and discusses the implications of the need to find the process or mechanism involved in order to develop new therapies.

Shereen Ezzat, M.D. (2008). Epigenetic Control in Pituitary Tumors Endocrinology Journal DOI: http://dx.doi.org/http://www.jstage.jst.go.jp/article/endocrj/advpub/0/0804240101/_pdf

One Good Thing - by Steve Owens

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I have a dear friend, Steve, who is suffering with Cushing's. I met Steve first online at cushings-help.com's message boards over 2 years ago where he was seeking help for a known adrenal tumor. He was passed around to multiple specialists and no one would do anything.

Steve was suffering mightily from the symptoms of Cushing's, yet no one would even test him for that. He persisted and pursued with two Cushing's specialists all the way across the country and was eventually diagnosed with ACTH-dependent Cushing's due to pituitary tumors. (Since many adrenal tumors are due to high ACTH stimulating the adrenals, it was hoped his would go away with the remission of the high ACTH.) He was referred by one for surgery which was done by a top-notch neurosurgeon at M. D. Anderson. Two tumors were removed, one from his pituitary and one from the sella floor.

Steve was not cured. The hopeful demise of the adrenal tumor did not happen, and he is now facing a bilateral adrenalecomy. It will happen next month. In the meantime, he as been on ketoconazole.

Not only does Steve face this after years of his body failing him due to the high ACTH, but his younger daughter is being tested for Cushing's, too. I've met Steve's family in person, and they are as dear as they come. His wife and girls are so supportive of him, and he continues to support others as much as he can in his fight for his life.

All of the above was simply to preface the story below. Steve wrote it and gave me permission to post it. (Love ya, my friend. I know how difficult this was.)

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One Good Thing

If there was ever any hope it is the hope that someday Cushing's will be easier to diagnose and to treat. That doctors will recognize the symptoms and tests are developed that lead from diagnosis to a cure in weeks, not years. If there is one thing I could want to come of all this, it is that. Not just for me, but for all of you, and especially my daughter. It is the hardest thing in the world looking into her eyes. I just want one good thing to come of all this.

These past few weeks have been filled with a lot of emotions, feelings, and just plain being scared. The closer the BLA gets, the more I don't like it. I have no extra spoons to spare to try and conquer the fear, because I am using them to get through each day. The days have been filled with doctors visits, testing for me and Brooke, and work. Nothing out of the ordinary, other than having an infection we cant seem to clear up.

It was at one doctor visit, with Doctor VJ, my family doc, that is the reason of my story. You see, I haven't seen her in a year. My weekly and bi-weekly visits have all been to endo's who are taking care of everything. Well, since they were out of town, I needed to see my family doctor. This is the doctor who wrote tests and she didn't know why, other than we asked for them. She couldn't read results because Cushing's isn't so black and white. This is the doctor who looked at me and knew I had Cushing's, once she read about the physical and not so physical symptoms. This is the doctor who told us my daughter has Cushing's, like her father. This is the doctor who scoured the medical books, talked to other doctors, and researched the internet to learn what she could to help her patients.

We would learn that Dr VJ would have a new patient come to her, one she suspected had Cushing's. Because the doctor took the time to care about me, she would notice the signs and symptoms and be able to run some tests. Because she was able to see a patient that had Cushing's in the past, she was able to see it in her new one. She was able to send her to my endo because she remembered she was helping us and others. This new patient is on the road to recovery already. She is going to be alright.

This made me stop and think. I found this doctor because of the goodwill of a lawyer. This lawyer spent 10's of thousands of dollars of his own money helping me fight and beat the insurance company. This is money he doesnt want back and will not take from us. He did it out of the goodness of his heart. His words were that "there are some things that are so fundamentally wrong in the world and I am just happy that I can help you right one of them." When our family doctor gave up on us, like so many others, he sent us to Dr VJ's office. From there, the doctor and our family grew into a team to help me get better.

I feel so humbled to meet people like these. There are good people in the world. I wanted to give credit to where it is due as well. It would be easy to say that the doctors learned because I did this....or I did that...and that would NOT be true. I know in my heart that I was led to people who could help me at the time I needed it most because I believed and we prayed. I feel humbled that God put me in these doctor's offices so that I could be an instrument of learning.

I believe that every thing we say or do can be remembered, for good or bad, by those around us. Sure, we remember the big things of our lives, but I have so many vibrant memories of the little things. It isn't the big presents I remember most and hold on to dearly. It is the small random acts of kindness that I cherish the most. Everyday, we have the ability to leave a mark on someone's life, even in the smallest of ways. None of us know God's will, but I believe that in that moment of time, when I was sick and out of options, He put me where He wanted me to be and that was the that doctor's office. I had never thought of it that way. I had ALWAYS prayed that something good would come from this to help the next person. If something good was going to come from it all, it was going to come from the powers of up above, not through my works or anything I could do.

My prayer was answered. I know that something good has come from this all, even if it has helped one single person. For that, I am thankful for my blessings. I am thankful for the brief clarity of mind to write it all down.

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One for the money, two for the show, three to make ready....

Just how many kinds of tumors are there associated with Cushing's? Wait, are we talking about pituitary tumors? Or adrenal tumors? How about ectopic tumors? Are you beginning to get the picture of why this illness is so hard to diagnose?

PITUITARY TUMORS/ADENOMAS:

So, let's talk about tumors. These are also sometimes called adenomas. Pituitary adenomas are classified several ways. They may be classified by pathology, by size, and by hormone production. I'm going to keep it simple here and list the basic types of tumors by the hormones they produce. Bear in mind that many pituitary adenomas produce more than one hormone. This production is not held in check by the body's normal feedback loops, thus they aren't controlled.

• Corticotroph (ACTH-Producing) Adenomas :
  The corticotroph adenoma secretes adrenocorticotropic hormone (ACTH), which results in Cushing Disease because it stimulates the adrenal glands to overproduce cortisol. These tumors are initially confined to the sella turcica, but they may enlarge and become invasive especially after bilateral adrenalectomy. This is called Nelson's Syndrome.
  
• Somatotroph (GH-Producing) Adenomas:
  Somatotroph adenomas produce growth hormone (GH), resulting in gigantism in younger patients and acromegaly in adults. These tumors may also extend beyond the sella.
  
• Thyrotroph (TSH-Producing) Adenomas:
  Thyrotroph adenomas secrete thyroid-stimulating hormone (TSH), also known as thyrotropin, which results in hyperthyroidism without TSH suppression. Many are large and invasive and typically have other types of adenoma cells included, such as ACTH and/or GH.
  
• Lactotroph (PRL-Producing) Adenomas:
  Lactotroph adenomas secrete prolactin (PRL) and are typically an intrasellar tumor. However, they can become large enough to enlarge the sella turcica.
  
• Nonfunctioning (Endocrine-Inactive) Adenomas:
  These tumors cause symptoms when they extend beyond the sella, which results in pressure on the surrounding structures such as optic nerves and carotid veins. They are not associated with clinical and biochemical evidence of hormone excess.
  
• Carcinomas:
  Pituitary carcinomas, although extremely rare, are usually endocrinologically functional, and ACTH-producing and PRL-producing tumors are the most frequent.
  
• Other Tumors:
  Other tumors of the pituitary include craniopharyngiomas, meningiomas, and germ cell tumors. Even rarer are the granular cell tumors, pituicytomas, and gangliogliomas. Most rare include gangliocytomas, lymphomas, astrocytomas, and ependymomas.

ADRENAL TUMORS/ADENOMAS:

When a tumor in an adrenal gland overproduces hormones, the tumor is called a functioning tumor. A tumor in an adrenal gland that does not produce hormones is, understandably, called a nonfunctioning tumor. A tumor can start in an adrenal gland (called a primary adrenal tumor) or it can begin in another organ, such as the lungs, and then metastasize (spread) to the adrenal glands. I'm going to focus on primary adrenal gland tumors.

• Adenoma:
  An adenoma is a benign nonfunctioning tumor of the adrenal cortex. Also called an adrenocortical adenoma, this tumor usually does not cause symptoms, and, if it is small, may not require any treatment. However, as it grows it can put pressure on parts of the gland causing it to under or overproduce hormones. The cause of adrenal adenomas is unknown, but the current accepted theory is that they arise because of mutations in certain genes. Adrenal adenomas are more common in some inherited diseases, including multiple endocrine neoplasia type I, Beckwith-Wiedemann syndrome and the Carney complex.
  
  Chronic adrenal stimulation by ACTH leads to bilateral adrenocortical hyperplasia and, if long-standing, nodular transformation according to recent research. Thus, an ACTH producing tumor of the pituitary or ectopic tumor may stimulate the adrenals to form tumors or become hyperplastic (more about hyperplasia in a bit).
  
• Adrenocortical carcinoma:
  Although exceedingly rare this is the most common type of malignant adrenal gland tumor, affecting the cortex, also called an adrenal cortical carcinoma. Adrenocortical carcinoma can be a functioning or nonfunctioning tumor. If the tumor is functioning, it may produce more than one hormone.
  
• Pheochromocytoma:
  A pheochromocytoma is a rare tumor that develops in the core of an adrenal gland. It secretes excessive amounts of catecholamines, usually epinephrine and norepinephrine.
  
• Neuroblastoma:
  Neuroblastoma is a disease in which malignant cells form in nerve tissue of the adrenal gland. It is very rare.

If that isn't enough, there is another form of tumor that isn't a tumor. It's called hyperplasia. These tumor cells may invade the pituitary or the adrenals in nests throughout the gland. Rather than go in-depth right now, I'll post some links to articles so you can explore the topic:

Pituitary Hyperplasia: A Review
Adrenal Hyperplasia

This is just a basic, no-frills outline of various tumors/adenomas associated with Cushing's Disease. And now....four to go.....to bed, that is....

Every journey has a beginning

Sure, every journey has a beginning, but sometimes it's hard to know when everyday life ended and the journey began. Or is all of life a journey and the illness just a rough patch in the road? Heck, I don't know. I just know that I don't really know when I started getting sick. And at this moment, that really doesn't matter. What matters is getting well.

You know, wellness is relative. Since perfection isn't readily achievable, and wellness would seem to me to be perfection, I guess none of us are really totally "well". However, there are degrees of wellness, and my journey has been an effort to achieve varying degress if it.

Maybe we need a wellness meter, something like a glucometer. "Well-o-meter"? I'll invent one when I get around to it. ;)

I'm not much of a philosopher, so I can't wax eloquent very well, but I do know how to tell it like it is. Thus, my attempts for this blog were born. In short, this is a blog about my journey with Cushing's Disease, but it really is much, much more than that. I've learned a lot along the way with the help of some wonderful friends. I hope to pay it forward somehow and help others. And I have the need to tell my story.