Cancer Brain Tumor

[music] narrator: "tumor" is one of themost frightening words a doctorcan say to a patient. and when a tumor is in someone'sskull base, it's even moreunpleasant. the anatomy of the skull base is particularly challenging, and the spatial relationshipsare very sensitive, so there's virtually no room forerror. narrator: the skull base is the area below the brain, but stillwithin the skull. it contains the bones around theeyes, the ear canals, some major arteries, and twelve cranial nerves.

it's a very complexarea because all theblood vessels that supply the brainand all the nervesthat come from the brain to the tissues travel through various openings through the skull base to get to thoseareas. so, when we're operating on tumors or other abnormalities in that area, you have to be careful to try topreserve those structures that are critical to supportinglife and other functions. narrator:dr. bob rostomily, dr. jay rubinstein, dr. larry duckert, and dr. neal futran operate in skull base surgeryteams at the university ofwashington medical center. tumors in the skull base are ina shared surgical area between neurosurgeons and ear, nose, and throat surgeons.

each one of us is passionate about what we do for these patients and their particular problem, and we each have a particulararea of expertise, even though we understand the broad concept of what the tumor is, and what the patient has to go through. but the great ability we have atthe university of washington medical center is, each of us can do the part we'rebest at, and then you put that together as a whole, and come out with the ideal treatment. it's the team. we are the team. narrator:while all surgical procedures are performed by teams, operations in the skull base involve two surgeons with different specialties workingin an extremely small space.

it's critical in this type of surgery, since you're working in a confined space, with very intricate structures, that you develop a rhythm withthe individual you're workingwith; you know each other's moves, and you work in concerttogether. it's much like having a dancepartner where each member of theteam has to know what the other isdoing to get that fluidmovement, to create theappropriate result. narrator:tumors in the skull base may damage one or more of the twelve cranial nerves, affecting a patient's vision,smell, facial movement, balance,or hearing. the most common of these raretumors are acoustic neuromas. these are benign tumors. they're slow-growing tumors.

they're very rare tumors; they originate in the general population somewhere in the neighborhood of 1 to 100,000. they generally are manifest by hearing loss, and they can also impact the balance, and they generally will alsocause tinnitus, which is headnoise. so, patients will commonly complain that they've developeda hearing loss in one ear. it's never both unless they have two tumors. and as the tumor slowlyenlarges, the hearing slowlydeteriorates. narrator: an acoustic neuroma, also known as a vestibular schwannoma, grows in an area heavilyprotected by bone, making itdifficult to reach, surgically. this is the temporal bone, the bone in which these tumors originate.

and more specifically, theyoriginate from this channel, which is the channel thatcontains the balance and hearingnerve, as well as the facialnerve. as they enlarge, they grow outof this channel and they grow towards the brain stem, which is sitting here. so, smaller tumors are going tolook like a mushroom cap with astem, and as they enlarge, they willgrow towards the brain stem. narrator:the way to diagnose these tumors is with magnetic resonance imaging, or mri. if a tumor is discovered, thereare a number of treatmentoptions, including radiation, surgery,or simply observing the tumor over time. sometimes no treatment isnecessary at all, depending on the age and the health of the patient.

there are many different ways to deal with them, and every tumor is individual. there are different factors youhave to weigh in the decisionmaking. right now, there's no right answer on how to treat these:to observe them, radiate them,or take them out. so, that's why it's reallyimportant, if you have a tumorlike this, for the patient to have theoption for any one of thosemanagements, at its highestlevel. so, having a team of people whoare experienced in surgery and radiation, all the different treatment options, in managing the patient pre- andpost-operatively, and having a center where youcan perform the surgery safelyand effectively is reallyimportant. in the removal of acoustic neuroma, a team approach has been developed

where neurosurgeons and neurotologists each use their different expertise to maximize the outcome of theprocedure in terms of benefitfor the patient. neurosurgeons have more expertise in dealing with tumors that involve the brain; neurotologists have more expertise in the anatomy of the temporal bone, and work with the nerves thatare traveling within thetemporal bone. narrator:this teamwork is critical to successful surgery. >> we're going to monitor the hearing interoperatively. so, the earphone is playingsounds into the ear and theneurologist will be recording the auditory brain stemresponse, in response to that.

for surgery, you have to have monitoring. that's extremely important forsafely removing the tumors and having the best outcomepossible for hearing and facialnerve function. and we have a dedicated team of neurophysiologists who help monitor hearing and allthe cranial nerve functionsduring surgery. how's the hearing?it looks good. in addition, we have neuro-anesthesiologists who are part of the team also. and they specialize in providinganesthesia for skull base and neurosurgical procedures. so, we all come together andwork on the patient's behalf, atone sitting.

narrator:the approach to surgery varies, depending on the tumor's size, location, and effect on the patient. >> there are a variety ofdifferent surgical approaches toacoustic neuromas, and dr. duckert tends to workmore through what's called thesub-occipital approach. i tend to work more through themiddle-fossa approach forhearing preservation, or the trans-labyrinthineapproach, if hearingpreservation is not an option. the trans-labyrinthine surgery is, of the three approaches,the one that will eliminate whatremains of the hearing. because the surgeon actually removes the bone which contains the hearing apparatus. this is the mastoid. the mastoid is removed. it's removed with a drill,

and as we drill deeper into theskull base, we encounter thebalance organ, and that balance organ is removed, in order to access the channel which contains the tumor. in the case of a middle-fossa approach, a window is opened along the lateral skull base. via that window, we then can approach the tumor from above. so, we're coming from thisdimension to approach the tumor from above. in the case of a sub-occipitalor retrosygmoid approach, the window is made behind the mastoid. and the surgeon then has accessto the tumor from behind. and once again, we can approachthe tumor within the channelthat contains it and any portion of the tumorthat is outside of that channel.

narrator:the cause of these tumors is not fully understood.so, who's at risk? >> acoustic neuromas can occur at all ages. the youngest person i'veoperated on for an acousticneuroma was eleven years old, but i've seen the first onset of an acoustic neuroma in the seventies, as well. any individual who complains of hearing loss or ringing in only one ear is at risk for havingone of these tumors. so, it's very important that anytime anybody complains ofhearing loss in general, but particularly hearing loss inone ear, that they be evaluatedfor acoustic neuroma. do you want to go down with me?do you want to sit?no. no? you just want to push me? wheee...

narrator:a couple of years ago, jamie youngquist had those symptoms. she heard ringing in her leftear, as her normal hearing onthat side gradually disappeared. an mri revealed a tumor, and atthat point, her doctor sent herto the university of washington medical center for treatment. >> we have a very close working relationship with referring physicians. it's a question of addressingtreatment alternatives, thendiscussing and deciding with thepatient which of those alternatives is going to be optimal, and then proceeding with the surgery, and then sharing the outcome of that surgery with the referring physician. and then of course, we maintaincontact with the patient. narrator:jamie and her husband, brad, met the members of the team, starting with dr. larry duckert.

>> he went into detail, justabout the three differentapproaches to get to the tumor, and really left it in our handsto decide which approach wewanted to take. and that, that was somewhat ofan easy decision just for us, just based on the numbers andthe statistics he gave us, andjust kind of the percentages ofhearing loss, post-surgery, and so, we pretty much knew after that which approach we wanted, and we went for it. and he was very, he was sooptimistic, that we just had allthe confidence in the world withdr. duckert. narrator:dr. duckert warned jamie that due to the damage the tumor had caused, she would probably have nohearing at all in her left ear. >> post-surgery, when i went back and saw him, he was very surprised, and we were all pleasantly surprised

that i could still hear about10%. i still have about 10%hearing in my left ear. which is great, because it, ican hear the ambient noise. ready? one, two, three! narrator:that residual hearing helps minimize jamie's tinnitus. >> if i lost complete hearing,the ringing would get worse without the ambient noise. so, the fact that i had a littlebit of hearing was a very goodthing. and i can notice when i get tired out that the ringing kind of is a little bit moreintense, but it's not a bother at all,by no means. narrator:post-operative care includes rehabilitation therapy,

to recover balance, when that particular cranial nerve has been affected by the tumor's removal. and there are regular follow-up visits. >> in as many as 60 to 70% of these patients, hearing will be preserved, and we'll be monitoring thehearing regularly, making surethat the hearing levels aremaintained. we'll also be monitoring them with regular imaging. depending on the size of the tumor, its location, sometimes a small portion of the tumor will be left behind. i don't mean inadvertently;it'll be left behind because toremove it we might anticipate that its manipulation wouldresult in some degree ofdisability, may lose somefunction. and in order to preserve thatfunction, we'll purposely leavea small portion of tumor behind,

knowing full well that in many cases that tumor doesn't grow; that the blood supply has been altered, so it just sits there. and then, the patient will be monitored on a regular basis with sequential imaging, to make sure that it's not goingto grow, or if it does, then we'd have to reconsider,and revisit other treatmentalternatives. so, these patients become good friends over many years as we continue to monitor them and make sure that they continueto do well. narrator: since her surgery, jamie and brad have had a daughter, and are expecting their secondchild soon. her tumor hasn't returned, andher life is back to normal.

free and clear. and i feel wonderful. ok, addy. there's twelve words here you'll hear. and all i want you to do is pick which word that you think you hear. so just go ahead and press it, and it'll start. pick one. narrator: an academic medical center combines the benefits of ongoing research with state-of-the-art patientcare. in dr. jay rubinstein's lab,they're testing new software forcochlear implants. addy is astar patient. >> previously, she was in a deafschool, and now she's been moved to a mainstream school. and her hearing has improved dramatically since we've been seeing her, so we're really excited about her progress. go ahead and listen to them and get familiar with them, and then when you're done with that,

just press start, and it'll playa melody, and then you pickwhich one it is. my research is on auditory implants in general. i work on signal processing strategies, to improve hearing with auditoryimplants. in the case of cochlearimplants, people already havevery high levels of speechunderstanding in quiet, so my laboratory at the virginiamerrill bloedel hearing researchcenter is developing improvedtechnologies that allow speech perception in noise, as well as better music perception with these devices. for people who have auditory brain stem implants, their ability to understand speech is far more limited, and our research is aimed attrying to improve basic levelsof speech perception. it's kind of fun, because ilike to hear things,

like voices where, laughter,like, people laugh, and i cantell voices, like if i ever talkto people, a group of people, and there'smusic or something, i can knowboth of them with each ear, and it helps me understand wherethe sounds are. narrator:while addy was born deaf, the research benefits patients who have lost hearing for other reasons, including tumors. there are wonderful techniques available now for rehabilitationof hearing loss in people who have had acoustic neuromas removed. for example, if one has normalhearing in the opposite ear,there is a device called a bone-anchored hearing aid that can be placed on the deaf side that restores hearing to that side.

the device allows the person tohear sounds that are on the deafside through their normalhearing ear. in people who have had acoustic neuromas removed from both sides, we have a technology called theauditory brain stem implant, where, after removal of anacoustic neuroma, we can place a hearing implant intothe brain stem, which restores some degree ofspeech recognition to thatindividual, so they do not need necessarily to lead out the rest of theirlives deaf. ator:dr. bob rostomily's skull lab serves as a training area for resident physicians, as well as a center forresearch. new surgicaltechniques are developed here. comparisons of exposure andangles of surgical access can bemade between new and oldapproaches,

all of it leading to betterpatient care. >> let's have a look with the endoscope, see how it looks. so, sometimes we can use the endoscope to actually get a much closer look, that can be viewed on thetelevision by the otherparticipants in the surgery, and it gives us the ability tolook at different angles thanthe straight-on microscope. endoscopic approaches, minimallyinvasive surgery, is becoming areal player in surgery of theskull base. the question is whether it'sreally better, and what are the limitations ofthat versus traditionalapproaches. the skull base is shared by multiple specialties, and this lab gives not only neurosurgeons,

but otolaryngologists and other surgeons the opportunity to perfect techniques that we'lluse in patients. and when we have specificpatient scenarios, we can work them out in the lab, so that when it comes time to go to the operating room, everything is worked out so it occurs flawlessly. narrator:dr. neal futran uses an endoscopic approach for surgery on sinus tumors, a technique that was developed and practiced in the lab. it's an endonasal approach,working through the nose to beless invasive than traditional surgery. >> traditionally, to get there,we would have to make anincision across the top of thehead,

remove a portion of the skull, and actually lift the brainaway to get to that area in between the eyes and the middle of the head. and so what we've been able todevelop is, using newer types ofapproaches that we use for sinussurgery, and actually extend thoseapproaches to move beyond the sinuses and remove tumors in the skull base. the other way that makes itextremely safe is we are able todo something called interoperative navigation. it's kind of like using a gps system for the middle of your head, where we can use computer-aidednavigation to know that whenwe're using these telescopes inside somebody's nose and inthe skull base, we can actually visualize the structures we want to save,

remove the tumor safely, andusually we're able to dischargethe patient within a couple daysof surgery, as opposed to a much longer hospitalization with the open approaches. narrator:another goal of research is to understand why some tumors cause hearing loss and some don't, and to possiblydevelop ways to reduce thatloss. >> we do have a research projecthere to try and compare tumors that have come from patients where, all else being equal, some have hearing and some don't, to determine whether there areother factors that influencehearing function preoperatively, aside from the usualexplanations of mass effect, orpushing on the nerve, or compromise from a blood supply standpoint.

we hypothesize that there mightbe some secreted factors, or some toxic factor thatcertain tumors create, thatinfluences the hearing function. this is a potential target thatyou could find therapies for, soif somebody wanted to watch a tumor, or was having fluctuatinghearing loss that you couldpotentially treat that. this is one of the tumors that we've actually been trying to do with the newer endoscopic approaches through the nose, using a skull base approach to minimize some of the side effects in a lot of thepatients. narrator:every day, there are opportunities for the team to share information informally. it enhances the team dynamic. >> the people who are involvedin our team, dr. futran,duckert, rubinstein, and myself,

are very interested in treatingthese complex cases, and in addition, have aninterest in asking questions about what to do, what we could do better, from the surgery side to minimally invasive techniques, standard techniques, and alsoasking questions about why wecan't, why things don't work sometimes, and the basic biology of these tumors, and how we can apply what we know about that to better care of the patient. what are the other alternatives,if you don't use the endoscopic approach? you could do a bifrontal craniotomy, or a unilateral craniotomy, and get this out from a moretraditional approach, larry.

yeah, but looking at this, thisis fairly central, there areopen sinuses. this would be one where if wecould approach it endoscopically, it would really limit themorbidity of the surgery, getthe patient out of the hospitala lot sooner, and we could likely get aroundthis with a minimal amount of effort that way. so, you and bob would do this together? the amazing thing to me about working with these guys is the immediate access we have with each other to help manage patients, and thewillingness we have to pitch inand help out, not only in a traditional way - because there are certain aspects of an operation or patient management that are more likely to behandled by an otolaryngologistor a head and neck surgeon,

or a neurosurgeon - but that weall are very, as neal pointedout - passionate about what we do, we really love what we do, and it's actually fun to provideservice when everybody's working together. and to me, that's the biggestreward for working at theuniversity of washington medicalcenter with this team.