Collaborative Approach Leads to Better Treatment, Outcomes for Tumors of the Skull Base

UH Neurological Institute - January 2017

Cliff Megerian, MD

 Nicholas Bambakidis, MD

 Warren R. Selman, MD

Tumors of the skull base can pose challenges to both patients and the surgeons who treat them. Although these tumors are not always cancerous, they are located in an area that is difficult to navigate surgically. If not managed correctly, there can be postoperative side effects, such as hearing loss or stroke.

The Center for Skull Base Diseases at University Hospitals Cleveland Medical Center brings together surgeons who are well-versed in attacking tumors of the skull base. With many years of experience, a multidisciplinary surgical team guides the best treatment for patients, leading to outstanding outcomes.

Diagnosing Tumors of the Skull Base

The kinds of tumors that may be treated at the Center for Skull Base Diseases at UH Ear, Nose & Throat Institute include acoustic neuromas, meningiomas, arteriovenous malformations, and pituitary tumors. Before patients are seen at the center, however, their path to diagnosis of a tumor may take a long time.

Some types of tumors or asymptomatic; others can have subtle symptoms, says Cliff Megerian, MD, Director, Chairman, Department of Otolaryngology – Head and Neck Surgery, Chair, Auditory Surgery and Hearing Sciences, UH Cleveland Medical Center, Director, UH Ear, Nose, and Throat Institute, President, University Hospitals Physician Services; Professor and Chairman, Department of Otolaryngology – Head and Neck Surgery, Case Western Reserve University School of Medicine.

For example, an acoustic tumor may present with subtle hearing loss, ringing in the ear, or dizziness. Ideally, the patient will share these symptoms with a primary care physician, who then refers the patient to an otolaryngologist. The otolaryngologist orders a hearing test and determines the patient has one-sided hearing loss. An MRI would then detect the tumor, which then leads to treatment or observation.

However, patients and their providers do not always follow this path, Dr. Megerian says. There are plenty of patients who may detect hearing loss but do not see a doctor for it; or, the hearing issue is misdiagnosed as an infection, and the patient is given antibiotics. Fast forward several years, and the patient has a larger tumor and a potentially riskier operation, Dr. Megerian says. “It’s something that we can take care of, but I’d prefer that it is diagnosed earlier,” he says.

“These tumors can be tough to pick up on because they tend to be more benign than your typical aggressive cancerous tumors,” says Nicholas Bambakidis, MD, Director, Cerebrovascular and Skull Base Surgery, Program Director, Neurological Surgery, Vice-Chairman, Department of Neurological Surgery, UH Cleveland Medical Center, Director, UH Neurological Institute; Professor of Neurosurgery and Radiology, and Vice Chair for Clinical Affairs, Department of Neurological Surgery, Case Western Reserve University School of Medicine. “They grow slowly and insidiously, so our bodies adjust to that a little easier because they can grow for months to years.”

Tumors in the skull base are challenging for several reasons, says Maroun Semaan, MD, Associate Director, Otology and Neurotology, and Director, Cochlear Implant Program, UH Cleveland Medical Center; and Assistant Professor of Otolaryngology, Case Western Reserve University School of Medicine. “These tumors tend to be in locations that are anatomically difficult to access, so they require special training and skills. Second, many times, these tumors can be close to critical structures, whether they are nerves or vessels that are critical. If you have an injury or loss to one of those, that can result in significant morbidity,” Dr. Semaan says.

The Value of Multidisciplinary Care

The challenges and risks associated with tumors of the skull base are met with confidence by the multidisciplinary team that works with the Center for Skull Base Diseases at University Hospitals Ear, Nose & Throat Institute. In fact, it is one of the busiest skull base programs in the U.S., treating 90 to 100 patients annually.

Depending on the type of tumor involved, the specialists involved in patient care include:

• Otolaryngologists
• Neurosurgeons
• Radiologists
• Ophthalmologists
• Endocrinologists
• Neurologists
• Oncologists
• Radiation therapists

Monthly and sometimes weekly meetings are held to review cases and plan treatments. “The patients get the best possible outcome for their problem, and that’s unique because not every institute has all of that expertise in one place,” Dr. Bambakidis says.

Although some patients require complex surgery, others are better suited for observation, to see how the tumor grows. Still other patients benefit from minimally invasive surgery, such as endoscopic approaches to the anterior skull base. “Instead of having a large incision, you can have almost no incision to treat some of these tumors. The length of stay is shorter, and patients recover faster,” Dr. Bambakidis says.

Use of Gamma knife radiation or proton beam therapy are yet other options that help to move a tumor away from critical structures in the skull base area.

“A good team understands when a tumor needs surgery or Gamma knife treatment or simply needs to be observed,” Dr. Megerian says.

The approach used also helps patients to preserve certain abilities, such as hearing—and that’s another reason that a multidisciplinary approach with experienced surgeons is so useful, Dr. Semaan says. For instance, certain kinds of tumors that involve the internal auditory canal can be treated with a detailed technique that helps to preserve hearing. “That wouldn’t be possible unless you have someone who is quite familiar with that anatomy and who has done this type of surgery,” he says.

Collaboration with colleagues is crucial for the management of many tumors of the skull base, says Warren Selman, MD, Neurosurgeon-in-Chief and Co-Director, UH Neurological Institute, and Harvey Huntington Brown, Jr. Professor and Chair, Department of Neurological Surgery
UH Cleveland Medical Center.

“For the patient, you are not getting someone who just has a hammer, and that makes everything look like a nail. We can collaborate in ways that allow us to state honestly what is best for the patient without a particular interest of our own,” Dr. Selman says.

Outcomes among the multidisciplinary approach for tumors of the skull base at the Center for Skull Base Diseases have been particularly strong, Dr. Megerian says. The survival rate for patients with skull base tumors is over 99 percent. However, a careful approach is needed to avoid complications such as nerve paralysis. At the Center for Skull Base, there is a 99 percent rate of long-term facial nerve preservation, he says.

Surgeons take an individualized approach with each patient to identify the best plan based on tumor size, patient age, and previous tumor growth patterns. “We use our collective knowledge and wisdom from well over 1,000 tumors treated collectively. We make the decision with patients and families for their tumor. Each tumor is different, and each patient is different,” Dr. Megerian says.