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Tiny tumor can fuel big appetite Cushing's disease gave prosecutor a life-threatening weight problem

Monday, February 16, 2004

News Staff Reporter

Old photos tell the story: The moon face, the chubbiness that was almost all in his belly, the relatively small backside and the short stature compared to his siblings.

But no one considered those things symptoms, least of all his doctors.

Friends, co-workers and family did notice and joke about First Assistant Washtenaw County Prosecutor Konrad Siller's primal urge to eat.

"You know it's too much. But your body is telling you it's starving," Siller said.

He understands that now.

But until he switched doctors in 2002, a small tumor, about the size of a dried split pea and buried inside the dime-sized pituitary gland in Siller's head, went unnoticed.

The benign Cushing's disease tumor had for years sent the level of cortisol, a natural steroid, raging out of control in Siller's body. His cortisol level was eight times higher than normal, putting him at risk for diabetes, high blood pressure, stroke, bone loss and, likely, an early death. And no matter how active he was - Siller mowed 25 lawns a week in the summer, worked out on a treadmill and exercise bike, and played with his three young and active children - he was still big, and getting bigger.

He started gaining weight after law school. By his late 30s, it seemed Siller was nearly as wide as he was tall.

Only 5 feet 4 inches tall, with brothers 6 feet tall, Siller will only say that he was a little closer to 300 pounds than 200 pounds, which still would have been far too much.

Even Siller noticed that a fat pad, a sort of "buffalo hump," had developed between his shoulder blades.

His mother and sister, both nurses, were worried by the time he was 37, in 2002, and told him so. His father, he said, "said he'd raised three kids, and he was not going to raise three more - meaning my kids, if I died."

All he could tell his family was, "I'm trying."

Siller did know he might have a do-or-die situation on his hands.

He found a new doctor, who measured Siller's "outrageously high" blood pressure at 170 over 124 and, within 10 minutes, proposed a diagnosis - Cushing's disease.

The disease, different from Cushing's syndrome, which has similar symptoms but no tumor, is uncommon, said University of Michigan neurosurgeon William F. Chandler.

"The big trick is making the diagnosis," Chandler said. He said the average time to diagnosis is about 10 years.

"The problem is that a lot of the features of Cushing's are things that are common in the population - obesity, hypertension, diabetes, fatigue and depression. And those things tend to run together" whether Cushing's is involved or not.

"But it's very important to diagnose it," Chandler said. The tumor is small, "but it really wreaks havoc with people's lives. It shortens their lives. But it's completely reversible if you figure it out, and take it out."

Chandler is a professor of neurosurgery and co-director of the Pituitary and Neuroendocrine Center at U-M. He also is the only surgeon at the medical center to operate on Cushing's tumors.

He started performing the surgery in the late 1970s - less than five years after a more-invasive form of the surgery was first developed. He now does 10-15 Cushing's surgeries a year.

The U-M clinic is one of only about half a dozen in the country where the surgery is performed - yet it's so noninvasive that patients are generally released from the hospital the day after the surgery.

Siller's diagnosis was confirmed with a blood test and a 24-hour urine test.

He was sent to an endocrinologist, who looked for a tumor with an MRI of the pituitary gland and CT scans of the chest and abdomen. The imaging tests came back negative, but Dr. David E. Schteingart was sure the tumor was there, Siller said.

So in April 2002, Schteingart threaded a catheter into each of Siller's two groin veins, through his body, and into his head, just beneath his brain. Siller was awake, taped down, and remembers a fierce itch on his nose that he was unable to scratch.

Every five minutes for about 90 minutes, his blood levels of ACTH, a natural hormone, were measured - and that told doctors where the tumor was located.

What it didn't tell them was that Siller had an unusually bony sinus structure. So in June 2002, when Chandler went after the tumor the first time, it could not safely be removed.

Chandler reoperated again later that month, this time using a "Stealth" computer-guided system.

Siller was asleep this time, when Chandler used an infrared camera to tell the computer where Siller's nose and ears were located in a three-dimensional space, literally mapping the inside of Siller's head with surface landmarks. That created a three-dimensional "map" for Chandler to use as he placed a 5-inch-long speculum through Siller's nose to reach the tumor in the pituitary gland at the base of the brain. Using the microscope and the tiny curette, he literally scooped the tumor out.

Siller's appetite dropped the same day. The next day, his blood pressure was down to 118 over 70 - normal.

Ironically, the surgery temporarily eliminates the body's ability to produce steroids - even the amount the body actually needs - so Siller had to go on steroid supplements. He cut back gradually, as his natural steroids kicked in, and was off the medication in five months.

Siller was off work for three weeks, weak and almost unwilling to eat for a while to the point that he worried his wife, Beth, and friends at the prosecutor's office - whom he had earlier awed with his drive to pack it away.

"I had to push myself to eat," Siller said. "How ironic is that?"

But his appetite stabilized, as did his physical strength.

The weight melted off. In 18 months, he lost more than 80 pounds. He's "well under 200" pounds now, and the weight is still coming off. His collarbones and his facial structure are visible, as is a space between his finger and his wedding ring. He lost the ring in his pocket once, when it just fell off.

The Salvation Army made out like a bandit - Siller handed off loads of suits and blazers, Polo shirts and jeans. He's dropped from an double-X shirt to a large, or medium, and lost 8 inches from his waist. He's gone from a 52-inch coat to a 46.

One court reporter was so startled, she blurted, "Where did the other half of you go?"

Siller's son Ben, who was 4 when Siller underwent surgery, only knew Daddy had to go to the doctor. But recently, Siller said, Ben made an idle remark.

"Your tummy is not as big as it used to be," he said.

Siller has, for some reason, lost a little of the strength in the grip in his left hand. Some of his skin is still thin, and he still bruises easily. He's got two small scars on his belly, where Chandler removed two small plugs of fat tissue to use to heal the internal wound in his head.

"It was tough going for a while. I was poked with more needles in a year than you should have to be poked with in your life," he said.

"But, I mean, it saved my life."

Susan Oppat can be reached at or at (734) 482-9495.

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