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Endoscopic techniques put out-of-the-way skull base tumors within minimally invasive reach

27.02.2003

They may cause excruciating pain, auditory or visual disturbances, dizziness and many other problems that compromise or eventually threaten life. They often grow for years, causing ever-worsening symptoms but evading detection and diagnosis. In fact, many tumors situated beneath the brain are considered benign because they don’t spread to other organs or increase rapidly in size, but they gradually interrupt blood flow, hormone production, and normal sensations as they grow and press against organs, nerves, vessels and other vital structures.

A California man diagnosed with an acoustic neuroma – a benign tumor that caused a ringing sensation in his left ear – learned that surgeons at two respected medical centers would need to temporarily remove a large section of his skull and shift his brain out of the way to reach the tumor. He could expect months of recovery and the possibility of neurologic injury from having his brain manipulated and nerves stretched.

Then he heard about the Skull Base Institute at Cedars-Sinai Medical Center, where innovative approaches, thin surgical instruments and precision optical equipment enable surgeons to remove skull base tumors through small holes. These minimally invasive techniques leave the brain undisturbed and significantly shorten hospital stays and recovery times.

For Marvin Quaas, 62, a resident of Cedar Rapids, Iowa, visual disturbances were the first sign that something was wrong. Driving to Canada for a fishing trip, he noticed that the 55 mile per hour speed limit signs had three digits instead of two. At first, he blamed the problem on the fatigue of the 14-hour drive. When the problem persisted, however, he made an appointment with an eye doctor friend who performed several tests.

“He said, ‘Marv, I hate to tell you this but you’ve got a mass on the right side of your brain,’” says Quaas. “I said, what? I was feeling just fine. Obviously, I went and had an MRI taken and met with my doctor, who confirmed that I had a tumor.”

Quaas went to a highly respected medical center for an evaluation, which turned out to be a good news/bad news situation. The good news was that the tumor could be surgically removed and most likely wasn’t cancerous.

“The bad news is it’s on your pituitary gland and wrapped around it, and we can only save that about 50 percent of the time,” Quaas recalls being told. “But you can live without your pituitary gland.” The physicians said medications could replace the hormones produced by the gland.

“The doctor said, ‘Your hairline isn’t going to help you too much because we ’re going to have to take about a quarter of your skull out, we’re going to cut this out, we’re going to move your brain over, and go down and repair it, come back out and put it back together,” says Quaas, noting that he began to have reservations, especially when he learned that the surgeon performs only about five such operations a year.

He was planning to seek a second opinion when his daughter in Dallas called. She had read an article in the paper about a Texas man who had had a skull base tumor removed in a minimally invasive operation.

Dave Galbraith of Duncanville was diagnosed in 2001 with an olfactory groove meningioma that appeared on an MRI like a cotton ball behind and between the eyes. Four neurosurgeons suggested several slightly different surgical approaches to remove the tumor but all agreed that “Texas Dave,” as he has come to be known, would lose his senses of smell and taste during the process.

After posting a message about his predicament to an Internet “chat room,” however, Galbraith received from a stranger an e-mail attachment describing fully endoscopic, minimally invasive procedures developed at Cedars-Sinai’s Skull Base Institute. He got in touch with Hrayr K. Shahinian, M.D., skull base surgeon and director of the Institute, who looked at the films from his MRIs and said he felt confident the senses of smell and taste could be preserved.

Still somewhat skeptical, Galbraith talked to two of Dr. Shahinian’s earlier patients. Reassured by their experiences, he underwent a four-hour endoscopic frontal craniotomy, a procedure pioneered at the Skull Base Institute that is informally known as the “Cyclops” procedure. Dr. Shahinian made a small incision between Galbraith’s eyes at the bridge of his nose. After Galbraith awoke in the recovery room, Dr. Shahinian waved a cotton ball beneath his nose, and the patient immediately recognized the odor of rubbing alcohol. The next morning, he gratefully enjoyed the aroma and flavor of hot coffee and hot cereal.

Before Marvin Quaas, the patient from Iowa, decided to go to Cedars-Sinai for surgery, he talked to Texas Dave by phone and even met Dave and his wife. “After talking to him, I decided – I’m going to California.”

Quaas, his daughter, son and brother all went. The day before the scheduled surgery, they met with Dr. Shahinian. “We spent probably two hours with him. I think he does a good job of communicating and winning your confidence. This is a passion of his and he communicates that very well,” says Quaas.

“On Wednesday, we checked in at like 7 in the morning. The thing that impresses me more than anything is the recovery. I checked in at 7. We had the operation. In 2 ½ hours, he had it (the tumor) out, and everything went just the way he had anticipated,” recalls Quaas. To reach the tumor, Dr. Shahinian made an incision in Quaas’s eyebrow and removed a dime-size piece of bone that provided access for the scope and instruments.

Dr. Shahinian uses endoscopes as thin as 2.7 millimeters and lenses that provide views straight ahead and at angles of 30 degrees and 70 degrees. These instruments make it possible to slide into extremely tight spaces and look around structures. From within the skull, the telescopes deliver a highly magnified and detailed picture to video monitors, enabling surgeons to remove a tumor completely and clear away all debris. A pneumatically operated robotic arm even holds the scope in place to make both of the surgeon’s hands available to maneuver the instruments, many of which have been designed by Dr. Shahinian and his team in collaboration with manufacturers of micro-instruments.

The route they take to reach a tumor is determined by its location. To remove an acoustic neuroma, for example, Dr. Shahinian makes a dime-size opening behind the ear, and some tumors in the area of the pituitary gland – beneath the brain and behind the nose – can be reached through the nose and nasal passages, leaving no external scar at all. No matter where the tumor is positioned, Dr. Shahinian’s objective is to slide the instruments around vital structures and under the brain to leave senses and function as intact as possible.

Quaas says he felt like he had been in a fight immediately after the operation, as expected, but recovery was quick. Although Dr. Shahinian gave him a prescription and suggested an over-the-counter pain medication in case he encountered a severe headache, Quaas says he never even needed an aspirin.

“I went in at 7 in the morning on a Wednesday morning and I walked out of the hospital at 10 a.m. Friday morning, 2 ½ days later. I walked out of there, went to the beach with my kids and my brother, and had lunch,” says Quaas. “I’ll tell you, if you want to talk to a guy who’s blessed, that’s me.”

Tom McCreery, 68, owner of a furniture store in Sacramento, says he feels oddly fortunate to have been misdiagnosed more than 35 years ago. Sometime in the late 1960s, he estimates, he suddenly developed double-vision, which lasted about a year and a half. Since then, he has experienced numbness on the left side of his face and a burning, scratchy sensation in his eye.

Based on his symptoms and tests at the time, doctors diagnosed multiple sclerosis and placed McCreery on medication to reduce his symptoms. Last year, however, he answered an ad for a body scan. “I thought, well, OK, how much has it (the MS) affected me? How much has it affected my brain? So I had the CAT scan done, I think on a Friday. On Monday I received a call from the doctor. She said, ‘Well, I don’t think you have MS. … Are you aware that you have a tumor in your brain?’”

McCreery’s son pointed him to Dr. Shahinian after researching skull base tumors on the Internet. “I look at it as just as well that it wasn’t discovered at the time I was having all these problems because I don’t think they would have been capable of operating on it, and if (they could have), it would have been a much worse operation than Dr. Shahinian performed,” says McCreery. By last August, when Dr. Shahinian entered through McCreery’s eyebrow to remove the tumor, it had grown to the size of a large egg.

McCreery says he took six weeks off work but felt he could have returned after three. “I came into the store like a week after I had the operation. The only reason I did was because I didn’t think they would believe me that I’d had an operation if they didn’t see the black eye,” he jokes, noting that the incision is no longer visible.

“I had a friend who had a similar operation at the hospital where I was first referred, and she was still having a lot of repercussions two months after,” McCreery recalls. “I had my operation and I was feeling fine.”

With training in general surgery, plastic surgery, microsurgery, craniofacial surgery and skull base surgery, Dr. Shahinian founded the Skull Base Institute at Cedars-Sinai in 1996.

Cedars-Sinai Medical Center is one of the largest nonprofit academic medical centers in the Western United States. For the fifth straight two-year period, Cedars-Sinai has been named Southern California’s gold standard in health care in an independent survey. Cedars-Sinai is internationally renowned for its diagnostic and treatment capabilities and its broad spectrum of programs and services, as well as breakthrough biomedical research and superlative medical education. Named one of the 100 "Most Wired" hospitals in health care in 2001, the Medical Center ranks among the top 10 non-university hospitals in the nation for its research activities.

Sandy Van | Cedars-Sinai Public Relations

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