BRAIN TUMOR DIAGNOSIS
he words from the doctor sink in . . “brain tumor.” Inner thoughts both chaotic and reassuring rise up in response: “At last there is an answer for my symptoms,” “We have a name for what’s been bothering me,” “Now what?” “I don’t even know where to begin with asking questions,” “Am I going to die from this?” “My life is changed entirely,” “Who will I trust to make sure I’m treated in the best way?”
And so it begins, the immersion into a new society, one of doctors, hospitals, tests, prognoses, plans, options, decisions. That brain tumor diagnosis comes with a specific name – not just a “brain tumor” but an astrocytoma, meningioma, adenoma, chordoma, glioblastoma, craniopharyngioma, or other name ending with “oma” (originating from the Greek for “growth,” “swelling,” or “tumor”). Your doctor provides information about the tumor, you read and learn about the tumor and how it will affect your health and your life, you research doctors and hospitals, and you move forward. During one of your followup visits, you are informed that, after tumor biopsy or removal, after imaging, after pathology review, the tumor is not what was diagnosed initially. A new set of questions arises: “Is this good or bad?” “What do I do now?” You need to rely on people who know about brain tumors that, according to the National Brain Tumor Society, number over 100 different types and subtypes. You go where the experts are. “It’s essential to have an accurate diagnosis so that the patient can be treated properly,” says Dr. Paul Gardner of the UPMC Center for Skull Base Surgery. “Different tumors require radically different treatments and that is just one reason patients should seek out a Center of Excellence, where expert physicians across disciplines care for people with a certain disease. With brain or skull base tumors, there can be a lot of subtle overlap in appearance and location, and only with experience and specialized imaging and histopathologic testing can we decide on proper treatment. Surgical expertise is critical to know when and how much to remove, which can be radically different for every patient and every tumor. Understanding this is key to ensure the best outcome.” Says Dr. Carl Snyderman, “The patient quality-of-life studies we are doing reflect our ultimate mission. Will someone be free of symptoms, first and foremost? Will the person have the absolute best long-term outcome? Beyond that, can the person continue to attend school, earn a living, go for hikes, take care of their children, and participate in all aspects of living that entail a full life for them? Patients come to us from across the United States and throughout the world, often after having consulted with many physicians. We see patients who come to us with no diagnosis or incorrect diagnoses. We take a fresh look at the person and, with the benefit of our own experiences plus the expertise of different specialists at UPMC devoted to brain tumors, we can have the patient worked up thoroughly and give them a definitive answer.”
The term, “Center of Excellence (CoE),” has its origins in manufacturing, aligned with the purpose of having experienced workers provide and pass along proven best practices in their areas of expertise. A concept that works well, for example, in routinely manufacturing cars with safe, reliable brakes was intriguing to those in medicine and healthcare. Physicians envisioned the CoE concept as a means to apply their expertise to ensuring patients get, reliably, the best possible health outcomes. Adapting Center of Excellence concepts to patient care means that specialty practitioners such as neurosurgeons are given opportunity to work closely with their counterparts in radiology, pathology, oncology, and other specialties focused on brain tumor research and treatment. Additionally, this concentrates care with high-volume surgeons, a factor that has been repeatedly shown to improve patient outcomes. Continued
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Brain Tumor Diagnosis . .
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“We understand the anxiety and confusion,” says Dr. Gardner, “when patients go from doctor to doctor, being presented different options for treatment and different diagnoses and prognoses, all in the context of worsening health. To be able to provide a clear diagnosis that sets in motion a plan for successful treatment is a privilege and one we are thrilled to offer from our Center.” Designated as a Center of Excellence for its innovative approaches combined with standard skull base approaches and interdisciplinary care, the Center for Skull Base Surgery carries on its pioneering work. As the first skull base center to be established in North America, developing both transcranial microscopic and endoscopic endonasal approaches to the skull base and brain, UPMC attracts the best and brightest physicians to UPMC, drawing in those who are enthusiastic to carry on that spirit of innovation in healing into the future.
UPMC FELLOWS . . Where are they now? hey come through UPMC training programs from all over the world. Four residents graduate from both the UPMC Neurosurgery and Otolaryngology programs each year. From this group and from other great training programs come physicians who further train in skull base surgery as “fellows”, refining their skills and gaining experience. Some go far afield and some return to their “home base,” to communities near where they grew up to bring their skills acquired at UPMC.
Nathan Zwagerman, MD, is in the latter group, establishing his practice close to his home after graduating as Chief Resident in Neurosurgery in 2017, which included a 2-year enfolded cranial base fellowship. He joined the faculty at the Medical College of Wisconsin/Froedtert Hospital as an Assistant Professor of Neurosurgery and Director of Pituitary and Skull Base Surgery. Dr. Zwagerman accepted the position in Milwaukee, in part, because it is almost directly across Lake Michigan from his childhood home in Holland, Michigan. “It’s fantastic to be back near Michigan again, now that my wife and I have 2 children and I can drive or take a boat back to where we are from and be in touch with family. It’s beneficial for us to have family closer to home.” As a young boy, Dr. Zwagerman went to play basketball on a team in a large regional high school in the Holland area. “I stopped growing at 6 feet in eighth grade, so no professional basketball career for me, but I love going to Bucks’ games and I still play for fun!” Dr. Zwagerman and wife Lisa attend a Bucks game (figure right). At Calvin College in Grand Rapids, Michigan, Nate studied biology as his major. After a few semesters of biology, he realized that he preferred people over plants, so he switched majors to pursue his degree in Psychology. Nathan took his college advisor’s recommendation to take the MCAT exam for admission to medical school as they discussed options post graduation. Continued next page
UPMC Fellows. . Where are they now? Continued from page 2 Passing the medical school exam landed Nate at Wayne State University School of Medicine in Detroit, Michigan. In his final year at Wayne State, Dr. Zwagerman was awarded the Golden Heart Award, which recognizes the hard work, compassion, and patience of deserving medical students and faculty. “That was such a big surprise to me. It’s voted on by peers and it meant so much to me to receive the award.” Eight years and over 400 miles from his life in Holland, Dr. Zwagerman made his way to UPMC and his studies in skull base surgery. “Maybe it all goes back to the brain connection that started with Psychology,” says Dr. Zwagerman, “my strong desire to work with the brain. I was doing my Neurosurgical Residency with Dr. Gardner and Dr. FernandezMiranda. I thought at first I would focus on vascular surgery, then asked Dr. Gardner and Dr. Fernandez-Miranda if I could do surgery with them, much of which was focused on skull base surgery. Skull base was not my original passion or goal, but then I began doing skull base procedures with them and it all clicked. Once I performed procedures on patients with skull base tumors, that was all I wanted and now my entire practice is devoted to skull base surgery.” “I still am in close contact with Dr. Gardner and the surgeons from UPMC Center for Skull Base Surgery if I face a new challenging situation with a patient. My relationships with colleagues and instructors at UPMC, my training and learning experiences while I was a resident there formed close bonds both personally and professionally. The professional bonds not only make us all smarter about our techniques but continue to expand the knowledge of skull base surgery.” Dr. Zwagerman and Dr. Gardner had an opportunity to catch up at the annual meeting of the North American Skull Base Society 2019 in Orlando, Florida (photo right). Word is spreading about Dr. Zwagerman’s and colleagues’ practice in Milwaukee. Dr. Zwagerman holds firmly to his convictions to “Treat people like people. Find out what they do. Don’t forget the person among the treatment and technical aspects of the work.” This is the conviction he passes on to residents and new faculty at the Medical College of Wisconsin. As most of us have come to assume about brain surgeons in general, Dr. Nathan Zwagerman’s list of continued accomplishments is the usual superhuman feat of degrees, awards, honors, research, authored publications, and innumerable surgeries. We expect, indeed, demand such prolific output of young, hardworking, gifted scholars who eventually become surgeons and educators. When expectations of that person as a young man were not that he would become a trained surgeon, but that he would take over the family farm, those accomplishments take on a very different perspective. Follow Dr. Zwagerman’s incredible “trail of the blue gloves.” Young Nathan Zwagerman, photo far left, holding his infant brother. Nathan wore those blue cotton gloves as part of his daily uniform working on the family farm in Holland. Dr. Nathan Zwagerman, photo near right, wearing the blue surgical gloves that are his daily uniform as a neurosurgeon. An inspiring account of Dr. Zwagerman’s journey from family farm to brain surgeon was presented in the Milwaukee Journal Sentinel, August 24, 2018. Accessible online: https://www.jsonline.com/story/news/ columnists/jim-stingl/2018/08/24/groomed-take-over-family-pig-farm-son-becomes-brain-surgeon/1077510002
UPMC PROMINENT AT NASBS ANNUAL MEETING
he UPMC skull base surgeons took on prominent roles at the 2019 North American Skull Base Society (NASBS) annual meeting. The annual meeting of the North American Skull Base Society was held in Orlando, Florida in February with 765 attendees.
A white paper co-authored by Dr. Carl Snyderman in collaboration with the NASBS was disseminated to all annual meeting attendees on the subject of Current Procedural Terminology (CPT) coding for endoscopic endonasal skull base surgery treatments. CPT codes must be used to report services to third-party payers and serve as the basis for reimbursement. The authors’ purpose in writing the paper was to address the knowledge gap and unfamiliarity regarding current coding options for endoscopic endonasal skull base procedures, providing clear recommendations and guidelines for coding. Dr. Snyderman and his coauthors clarified reimbursement implications for surgeons, coders, billers, and third-party payers with the goal of routine and proper payment of health insurance claims for endoscopic endonasal skull base surgery. Ultimately, this helps patients get the surgery that they need. Dr. Paul Gardner was a co-chairman of the Hands-on pre-meeting dissection course during which lectures and supervised surgical anatomic dissections were presented. The course was filled to capacity, deeming the experience as a high point of the meeting. Dr. Eric Wang led a session of the pre-meeting course on endoscopic anatomic dissections with Dr. Juan Fernandez-Miranda. Faculty and participants of the NASBS 2019 pre-meeting course on anatomic dissection:
zequiel Goldschmidt MD, Resident in Neurological Surgery at UPMC, received an impressive 100% acceptance for his submissions to NASBS. He presented a total of four talks at the 2019 annual meeting. According to Dr. Gardner, “Even more impressive than having all his submissions accepted, three of the four talks he was invited to present are based on concepts and work that are entirely his. The future of neurosurgery and brain tumor research is in great hands with doctors like Dr. Goldschmidt.” The subjects of Dr. Goldschmidt’s presentations are:
Imaging and Demographic Characteristics Associated with Invasion of the Medial Wall of the Cavernous Sinus in Patients with Invasive Pituitary Adenomas
Cerebrospinal Fluid Leak can Inhibit Wound Healing by Inhibiting Angiogenesis
Insulin Promotes Cellular Growth in an in vitro Model of Mucosal Healing after Endoscopic Endonasal Approaches
Regenerated Oxidized Cellulose (SurgicelTM) Induces Nasal Epithelial Necrosis in vivo by Acidifying the Cellular Environment
Video: Advances in Techniques in Skull Base Surgery: https://www.youtube.com/watch?v=pEUXuZ81U4M
THIS TEAM NEVER HAS AN “OFF SEASON”
inter break? Not for the faculty from UPMC Center for Skull Base Surgery. No slowing down for Dr. Carl Snyderman, Dr. Paul Gardner, and Dr. Eric Wang as they extend their expertise around the globe and across North America in 2019 as sought-after faculty for skull base courses.
Dr. Gardner and Dr. Snyderman were Course Director and Course Faculty, respectively, at “Innovations in Endoscopic Minimally Invasive Brain Surgery: A Hands-On Course,” held at Advent Health in Orlando, Florida in January. The Gardner-Snyderman surgical team presented lectures at the Department of Neurosurgery, Salvator Mundi International Hospital, Rome, Italy in February: Dr. Snyderman lectured on “Evolution of skull base surgery” and Dr. Gardner presented lectures on “State-of-the-art of minimally invasive cranial surgery.” February had Dr. Eric Wang in Seoul, South Korea at the 3rd Annual Meeting of the Korean Society of Endoscopic Neurosurgery. Dr. Wang presented “Clival chordoma: endoscopic transclival resection and molecular prognostication” at a pre-meeting symposium. During the annual meeting, he presented multiple lectures: “Contralateral transmaxillary approach to the petrous apex,” “Recent updates of reconstructive methods after endoscopic skull base surgery,” and “Transpterygoid approaches to the pterygopalatine fossa and skull base.” Back in the States, in March, Dr. Gardner lectured at the Lawrence County Medical Society in New Castle, Pennsylvania on the subject of “The role of endoscopic endonasal surgery in modern neuro-oncology,” and at the 17th Annual Masters’ Course in Skull Base Surgery in Tampa, Florida on the subject of “An update on indications and limits of the endoscopic endonasal approach to the skull base.”
Dr. Snyderman presented lectures at the Charles W. Gross Symposium on “The Nose: Inside & Out,” at the University of Virginia, Charlottesville in March on “Surgical management of angiofibromas,” “Concepts in endoscopic skull base surgery: choosing the right approach,” “Modern reconstruction of skull base defects,” and gave a video presentation on “Nasoseptal flap reconstruction.” In April, Dr. Snyderman lectured on “Innovation and creativity in surgery at the Chicago ENT Society in Chicago, Illinois and “What’s new in skull base surgery?” at Grand Rounds for the Departments of Otolaryngology and Neurological Surgery at Loyola University Medical Center in Maywood, Illinois. The Center for Skull Base Surgery team is well underway with preparations for their UPMC training courses and workshops held in Pittsburgh annually in May, July, and November for skull base surgeons around the world.
UPMC ON ACADEMIC JOURNAL COVER uthors from UPMC Departments of Neurosurgery and Otolaryngology were informed that a figure from their article will be published on the cover of the prestigious Journal of Neurosurgery. The figure is from their article “Endoscopic endoscopic transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series” published April 2019. https:// thejns.org/
Authors of the article to be published in the journal are Drs. Cristian Ferrareze Nunes, Stefan Lieber, Huy Truong, Georgios Zenonos, Eric Wang, Carl Snyderman, Paul Gardner, and Juan Fernandez-Miranda. Founded in 1944, the Journal of Neurosurgery (JNS) is recognized by physicians worldwide for its authoritative clinical articles, laboratory research papers, case reports, literature reviews, technical notes, and neurosurgery-related historical pieces. The Journal of Neurosurgery is cited more often than any other journal dedicated to the field of neurosurgery. “We are honored that the editor-in-chief of the journal selected our paper as the cover article,” says Dr. Eric Wang, “With so many excellent scientific articles and illustrations in the journal, to have one of our figures selected for the cover is indicative of the relevance and importance of our work to the surgical and scientific community.”
Center for Skull Base Surgery University of Pittsburgh 203 Lothrop Street Suite 500 Pittsburgh, PA 15213 Directors: Paul A. Gardner, MD email@example.com Carl H.Snyderman, MD firstname.lastname@example.org
In future newsletters, you will learn more about new clinical, research, and educational projects initiated at the Center for Skull Base Surgery. Your support is essential.
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The University of Pittsburgh Skull Base Team is pictured above: Dr. Eric Wang, Dr. Paul Gardner, Dr. Carl Snyderman
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