Treatment of skull base tumors, including those affecting the pituitary gland, traditionally entailed opening the skull or making large incisions in the face and removing parts of the facial bones. These invasive procedures caused significant pain and scarring and required long hospital stays.
Penn State Health Milton S. Hershey Medical Center has marshaled clinical and technological advances in this field and assembled the only skull base surgery team in the region, incorporating safer, less invasive techniques and making comprehensive care available locally for patients with skull base tumors.
The team includes otolaryngologists, otologists, head and neck surgeons, neurosurgeons, ophthalmologists, oculofacial plastic surgeons, medical and radiation oncologists, and other clinical staff, who have regular tumor board meetings to develop individualized treatment plans. Courses of treatment may include different combinations of minimally invasive or open surgery, chemotherapy, highly targeted radiation, and reconstructive surgery, depending on patients’ needs.
The most advanced approaches to skull base tumors not only effectively treat the condition but also minimize risk and preserve or restore optimal function and quality of life. This requires extremely precise techniques, which, in central Pennsylvania, Milton S. Hershey Medical Center is uniquely positioned to provide.
“The skull base is a highly complex anatomic region that houses many of the nerves that make us who we are and allow us to interact with others and the world,” says Meghan Wilson, MD, skull base surgeon and pediatric otolaryngologist at Hershey Medical Center. “The nerves that give you vision and eye movement travel through the skull base. So do the nerves that provide sensation and movement to the face as well as voice and swallowing functions.”
To protect those critical functions, surgeons at Hershey Medical Center prioritize nerve preservation during tumor resection.
“Disruption of any of these nerves has a major impact on quality of life,” Dr. Wilson says. “We take that very seriously.”
Minimally Invasive Procedures
Endoscopic resection of skull base tumors is a vital technique for preserving function and otherwise enhancing outcomes. Skull base surgery takes place near the base of the intracranial cavity. However, instead of making a large incision in the skull or face, specialists at Hershey Medical Center typically perform resection with a camera-equipped endoscope guided through the nose.
Pituitary surgery, the most common skull base surgery, is often performed this way. Located below the brain and above the nasal passages, the pituitary gland releases hormones essential for regulating a range of bodily functions. Most pituitary tumors are benign, but even noncancerous tumors can cause serious conditions by pressing on the optic nerve or making the pituitary gland generate incorrect amounts of certain hormones. This can cause headaches, infertility, erectile dysfunction and other symptoms.
To address pituitary tumors, surgeons at Hershey Medical Center utilize a transsphenoidal approach.
“The sphenoid sinus is situated deep inside the head, approximately 7 centimeters back from the nostril and immediately in front of the pituitary gland,” Dr. Wilson says. “A skull base otolaryngologist removes the back wall of this sinus to give access to the pituitary gland for removal of the tumor.”
With this minimally invasive technique, surgeons avoid contact with the brain and leave no visible scar. Afterward, many patients are able to leave the hospital within a couple of days and have little pain. Endoscopic surgery is as effective in removing tumors as open surgery but poses fewer risks to crucial nerves and blood vessels. When necessary, surgeons can also make small incisions near the eyes and ears to gain access for minimally invasive tumor resection.
“It’s always humbling to consider the high stakes,” said Dr. Neerav Goyal, Associate Professor of Otolaryngology-Head and Neck Surgery and Director of Head and Neck Surgery at the Penn State Cancer Institute. “The skull base region contains a complex anatomy of vessels and nerves where injury of these structures can lead to stroke or the loss of vision. Fortunately, having an experienced and collaborative team of surgeons that is cognizant of the risks, helps keep these concerns to a minimum.”
“Penn State Health Milton S. Hershey Medical Center is the only center in the region that brings together fellowship-trained experts in these subspecialty areas with the framework, facilities and technology to tackle such pathologies at the highest level.”
— Brad Zacharia, MD, assistant professor of neurosurgery, co-director of the neuro-oncology program and director of brain tumor and skull base surgery at Penn State Health
Among the state-of-the-art technologies Hershey Medical Center employs to treat skull base tumors is the Leksell Gamma Knife Icon.
Stereotactic radiosurgery performed with Gamma Knife is noninvasive and enables radiation oncologists to deliver radiation precisely to a tumor — often in a single session — protecting surrounding healthy tissue. Patients generally return home the same day.
“When we’re dealing with these critical structures at the base of the skull, accuracy is paramount,” says Brad Zacharia, MD, Assistant Professor of Neurosurgery, Co-director of the Neuro-Oncology Program and Director of Brain Tumor and Skull Base Surgery at Penn State Health. “The Gamma Knife has really changed the way we manage patients. Prior to radiation techniques like this, the surgeries were much more radical because there were no other options. Now, we’re able to sculpt the radiation in exquisite detail to converge on our target and deliver a high dose.”
Rare Pediatric Capabilities
In addition to its regionally unique arsenal of treatments for adults with skull base tumors, Hershey Medical Center is the only hospital in central Pennsylvania with a pediatric skull base surgery team.
Most children with skull base tumors are treated by nonpediatric physicians, often in facilities geared toward adults, but pediatric tumors differ from adult tumors, as do children’s medical, psychological and other needs. That makes access to a pediatric-trained team critical for young patients. Dr. Wilson is one of only a small number of U.S. surgeons trained in both adult and pediatric skull base surgery.
“That’s one of the unique features of our program,” she says. “We’re experienced in treating children as well as adults.”
Pediatric skull base procedures use specialized equipment tailored to children’s anatomy and are performed at Penn State Children’s Hospital on the Hershey campus.
The local availability of this level of care spares families in central Pennsylvania the burden of traveling significant distances for advanced treatment of skull base tumors.
“Patients in the region would otherwise have to go to major metropolitan areas — Philadelphia, Pittsburgh, Baltimore, Manhattan — for a similar level of care,” Dr. Wilson says. “We offer sophisticated, comprehensive treatment close to home, so adult and pediatric patients alike can have the support of friends and family, which is essential in their treatment, recovery and overall well-being.”
For additional information about skull base surgery at Hershey Medical Center, visit hmc.pennstatehealth.org/skull-base or call 717-531-3828.