By Steve Blanchard - November 29, 2022
The two doctors operate side by side, navigating the intricacies of the human skull and nasal cavity to remove rare tumors that can impair a patient’s cognitive functions. Andre Beer Furlan, MD, PhD, a neurosurgeon with Moffitt Cancer Center’s Neuro-Oncology Program, and Krupal Patel, MD, assistant member in the Department of Head and Neck–Endocrine Oncology, work as a team on these delicate endoscopic surgeries, removing skull-base tumors without having to open the skull itself.
Skull-base tumors, as the name implies, are typically found at the base of the skull or near the top of the spine. They can often form in the frontal sinus cavity near the pituitary gland.
“Skull-base tumors are not formed in the brain itself,” Beer Furlan explained. “But all functions of the body can be impaired by these tumors since they press against vital nerves and arteries that control our motor functions and senses.”
Historically, these tumors would require an open craniotomy, where doctors physically open the skull above or behind the ear to reach the tumor area. But such intrusive and traumatic surgery is not always necessary, thanks to innovative doctors such as Beer Furlan and Patel. This multidisciplinary Moffitt team uses endoscopic surgery to remove hard-to-reach skull-base tumors, with better results and speedier recovery times.
Their efforts proved to be a lifesaver for Pedro González Escolá.
Early Discovery Leads to Quick Action
Fortunately for González Escolá, 40, his tumor was discovered before his motor functions and senses were impacted. A routine blood test showing elevated hormone levels prompted the discovery.
“I went in for a checkup and did blood tests,” he said. “They found a high number connected with my hormone level, so he [the doctor] sent me to get an MRI.”
That MRI revealed González Escolá had a growth on or near his brain. Even though he was not showing any physical symptoms related to the tumor initially, his doctor suggested he seek out an oncologist’s help.
“That MRI was done in September 2021, and I was at Moffitt on Jan. 10 for a follow-up,” said González Escolá, who decided to make the trek to Moffitt from his home in Puerto Rico based on advice from his brother, who trained as an oncology surgeon at Moffitt. “On Jan. 11, they told me I had a malignant tumor and suggested I have surgery as soon as possible.”
Moffitt doctors told González Escolá that the two possible tumors with those imaging features were chordoma or chondrosarcoma, both considered slow-growing cancers of tissue found at the base of the skull near his pituitary gland.
González Escolá said his brother, who is a doctor in Puerto Rico, helped keep him calm after his diagnosis and explained that technology had advanced a lot in this area of oncology. “He reminded me that it was 2022 and not the 1990s,” González Escolá said. “The technology is so much better now, and I was relieved that they didn’t have to go through my skull, which meant less time in the hospital and a faster healing process. It’s still a brain surgery, essentially, but it’s less invasive.”
In the time between his diagnosis and his visit to Moffitt, González Escolá’s tumor was pressing against a nerve connected to his vision and eye movement. González Escolá and his wife discussed his options in depth with Beer Furlan and Patel and ultimately agreed to the endoscopic surgery.
González Escolá said he was impressed with both doctors’ bedside manner.
“These two doctors explained everything so well and were so caring,” he said. “They explained the procedure and how they would remove the tumor through my nose and avoid having to open up my skull. They were straightforward and so respectful.”
González Escolá was admitted into Moffitt on Jan. 21. At the time, he told his doctors he had double vision, which they determined was directly connected to the tumor growing in his skull. He had his surgery on Jan. 28.
An Intricate Surgery
Removing a tumor can take anywhere from six to 12 hours of surgery, and the doctors physically remove the cancer through the patient’s nasal cavity. González Escolá’s surgery lasted about 10 hours.
“Pedro’s surgery took so long because the tumor was so calcified,” Beer Furlan said. “Because the tumor was in a cavernous sinus area, when you manipulate that you get a lot of bleeding. It was also very close to nerves and the carotid artery, so it’s a very delicate area.”
Beer Furlan and Patel both worked on González Escolá and used drills to release a block of bone connected to the tumor and extract both the hard and soft tissue through his nasal cavity.
“In a case like this, we work through both nostrils, the right and left side,” Beer Furlan said. “Dr. Patel opens the sinuses and makes one larger cavity in the back of the nose. We use a four-hand technique to remove the tumor and to control the bleeding as we extract the cancer.”
After the tumor’s removal, Patel reconstructed González Escolá’s nasal cavity using a nasoseptal flap so the patient could begin to heal.
Faster Recovery with No External Scars
This procedure is relatively new at Moffitt, and in the program’s first year, 38 surgeries were performed. That number will gradually increase as the program grows.
“Skull-base tumors are rare, and a majority tend to have benign behaviors,” Beer Furlan said. “But they can cause problems, and recovery is much easier with this new method.”
"The nose acts as a natural corridor to these very complex areas, and the technology of endoscopes allow us to operate in the space and visualize these critical structures that would not otherwise be available."- Dr. Krupal Patel, Department of Head and Neck–Endocrine Oncology
That’s because “the nose acts as a natural corridor to these very complex areas, and the technology of endoscopes allow us to operate in the space and visualize these critical structures that would not otherwise be available,” Patel said. He noted that in addition to the faster recovery times, patients also have no external scars.
Both Patel and Beer Furlan agree that while there are risks associated with an endoscopic surgery, those risks are not as great as traditional surgery, which requires more healing time because of the trauma caused by simply reaching the tumor.
Beer Furlan is quick to point out that not every patient is a candidate for this type of surgery. “It is important to understand that not all tumors in the skull or brain are removed this way. Each type of tumor has its own treatments, and it’s important to discuss those with your doctor,” he said.
Symptoms and imaging are key to ensuring the correct treatment protocols are followed. “We do that [endoscopic surgery] for tumors that are asymptomatic and have very benign features on the MRI and CT scans,” Beer Furlan said. “Other tumors may require an open craniotomy for resection or a combination of approaches. Radiation therapy may also be needed as an adjunct treatment, depending on the type and grade of the skull-base tumor.”
‘I Can Live a Normal Life’
As with most cancers, skull-base tumors fall on a scale. A grade 1 chondrosarcoma, which González Escolá had, is a best-case scenario, Beer Furlan explained.
González Escolá recalls waking up in the intensive care unit with a bandage under his nose and his wife at his side. He knew he had come through his surgery, but he was surprised when a physical therapist entered his room and encouraged him to stand.
“I wondered if they knew that I had just had brain surgery 11 hours earlier,” he said. “I was surprised they wanted me to try to stand so soon!”
González Escolá said he not only stood next to his bed for a few minutes, but he also took a few steps, which showed that he was already on the road to recovery.
Since his surgery, González Escolá has returned to Puerto Rico, is back at work in medical coding and auditing, and is pursuing a law degree. He said he had some minor vertigo after the surgery and just a little pain.
“I didn’t have any headache, which I think is just amazing,” he said. “I can’t smell, but even if that sense doesn’t come back, I’m thankful that I can live a normal life.”
"We don’t fully understand these tumors, and we want to make sure that we continue monitoring to ensure the cancer doesn’t reappear."- Dr. Andre Beer Furlan, Neuro-Oncology Program
Patel said González Escolá could regain his sense of smell in a matter of months but stressed that each outcome is different.
Moving forward, González Escolá’s normal life will include continuous monitoring and several trips back to Moffitt throughout the year to ensure he is still healthy. He will start out being monitored every three months, then every six months and eventually, just once a year.
“We don’t fully understand these tumors, and we want to make sure that we continue monitoring to ensure the cancer doesn’t reappear,” Beer Furlan said.
Building Hope for Others
Fortunately, González Escolá has the support of his wife, Yolanda, and family and hopes that his experience can help others.
Beer Furlan said the tumor he and Patel extracted from González Escolá is now part of a database that will help doctors understand their pathology.
“We are building a patient database of tumors and combining those with other centers of excellence around the nation to look at outcomes and impacts to patient survivorship, quality of life, etc.,” Beer Furlan said. “There is so much more to this than just the surgery. These tissues help us understand why some tumors have benign behaviors and others take a different course. That tumor biology will help us learn and have a positive impact on many other patients.”
Knowing his experience can help others gives González Escolá a sense of hope and peace. But even as a cancer survivor, he said it can be hard to know what to say when someone you know is facing their own cancer diagnosis.
“Only the one suffering knows what it’s like in their individual situation,” he said. “But treatment is so important, and you have to focus on the positive. Chemotherapy and treatments are so much more advanced than they used to be, and there are more tools to survive now than before. You must keep the hope. Hope, along with the support of my wife and my amazing doctors, is what saved me.”
This article originally appeared in Moffitt's Momentum magazine.