Center for Skull Base Surgery, Summer 2018

YOUR BRAIN IN 3D It’s been done to create prostheses, to create bone scaffolding and heart valves, and to create ear cartilage. It’s been used to replace portions of skulls. Now a team from UPMC Radiology and Neurosurgery are using the technology of 3D printing to create models of the brain for planning surgical cases with pinpoint accuracy.

“We essentially created 3-dimensional models of four pre-operative clinical cases in patients who were about to undergo surgery,” says Sandip Panesar MD, post-doctoral fellow at University of Pittsburgh Department of Neurological Surgery, now at Stanford University. “The models were created from routine neuroimaging sequences at UPMC’s 3D printing lab.”

The UPMC 3D printing lab was founded in 2016 by Anish Ghodadra MD. Its mission is creating low-cost, patient-specific 3D-printed models to aid in patient care. By creating models of a patient’s unique anatomy and disease, physicians can better understand the specific nature of that patient’s injury or illness. Says Dr. Ghodadra, “3D models allow physicians to better plan and, in some cases, even practice treatment for a patient. Patients can also get a better understanding of their disease. Holding a model of your own brain, kidney, heart, or knee can give insight into your disease in a way that just isn’t possible using traditional techniques. With this insight in-hand, patients better understand the full scope of their disease and treatment and can play a more active role in their care.” Dr. Ghodadra’s research interests in 3D printing and advanced image processing correlate perfectly with one of his clinical specializations in interventional oncology, creating a relevant and technologically advanced laboratory-to–operating room benefit to the neurosurgical patient.

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In the photo series above, the far left picture is an MRI scan showing a very large brain tumor lying on the brain’s central membrane. The center and right photos are 3D printed models of the same patient’s skull, tumor, veins and arteries from a back-front view. The 3D “cutaway” depicts clearly the surrounding anatomy that surgeons will encounter when they approach the tumor. In addition, the model can be disassembled to give alternate angles of view, providing surgeons with full information to plan their operative approach.

Online access to links in this issue at ISSUU: https://issuu.com/search?q=UPMC+center+for+skull+base+surgery

Your Brain in 3D . .

Continued from page 1

The left image is an MRI scan of a patient’s brain tumor.

The right image is the 3D printout of a section of the patient’s skull, tumor, arteries and veins.

The addition of arteries and veins in the model allows surgeons to visualize delicate anatomical structures surrounding the tumor in 3-dimensions, enabling them to be aware of areas to avoid or areas to proceed with extreme caution.

Dr. Panesar says that, “Since 3D brain modeling is a relatively new technology, we are still exploring its integration into the clinical aspects of neurological and ENT surgery. Skull base surgery naturally lends itself to 3D printing because skull base anatomy is considered to be very complex. Skull base surgeons may face a steep learning curve to master the anatomy of the skull base; hence, my rationale to see if these rapidly-prototyped models would be useful for visualizing skull base anatomy and pathology. In addition to skull base tumors, we applied the technique to a general neurosurgical case as a further demonstration of the technology. After creating the 3D printouts, we used a questionnaire to collect feedback from senior neurosurgeons and trainee neurosurgeons. We found that generally the models were well liked by both groups. The senior neurosurgeons are enthusiastic about the use of 3D models for pre-operative planning. The trainee neurosurgeons appreciated the 3D models for learning anatomy.”

Anish Ghodadra, MD

Sandip Panesar, MD

“Good Day!” from the

A professional, crisp, polite, to-the-point, welcoming, efficient email message might be the first contact, or for that matter, the o professors, universities throughout the globe, professional organizations - all, at some point, are in contact with her as she goe Center for Skull Base Surgery.

From the Center offices, through the frosted-glass panels of her work area, you can catch snippets of a “day in the life” of Mary • To Dr. Snyderman: “The article you authored is in your Inbox for your final review and I’ve booked you through Heathrow n •

To Dr. Gardner: “Do you want an interpreter when you land in Kazan? I did get your message about the surgery scheduled

•

To Dr. Wang, “Do you have any more course materials you want to send for the conference? A fellow is on his way to see

•

To a visiting UPMC skull base course participant, “This is the map, the anatomy lab is here, be sure to bring the packet yo

•

To UPMC staff members, “I’ve got the financials you requested,” “I set up 5 more people on the new system; can you con meeting abstracts,” “The conference room is ready, you just need to connect your laptop for the presentation through this

•

To a visiting professor, “How is your hotel? Everything satisfactory? Do you need anything? Did you like the restaurant we

To access Mary Jo in person, you might need to make your way from the door across a floor carpeted with briefcases that sh When you reach her desk, you’ll find command central, and there is Mary Jo Tutchko in her role as Project Manager, laser-foc details enables the skull base surgeons to focus on their priorities of patients and teaching. Mary Jo is proud of her “backgrou perform their surgeries, do research, and teach.

Dr. Snyderman concludes, “Without MJ, we wouldn’t be able to function. She keeps everything moving like clockwork!” Fashio the Center’s beating heart, gracefully and adeptly maintaining the steady pulse that drives the Center’s work.

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Your Brain in 3D . .

Continued from page 2

The picture above shows the patient’s CT scan on the left, with the arrow pointing to the brain tumor. The center photo is the 3D printout of the tumor encased in the skull and the photo on the right shows only the tumor, which can be removed from the skull model. The surrounding arteries are elucidated in great detail, indicating that some arteries are actually passing through the tumor.

Dr. Panesar talks about the educational benefits of such 3D models. “The UPMC Radiology team appreciates the application of this technology to educate patients about their condition and the treatment approaches that neurosurgeons may use. Says Dr. Panesar, “Patients may struggle with understanding complex medical terminology, scans or treatment methods. These models give patients a direct, 3D visual aid which may enhance their understanding of their disease or disorder.” “A patient can so much better tangibly understand their disease and treatment holding a model of their skull and their tumor as compared with viewing images that are often difficult to interpret,” says Dr. Ghodadra. See Dr. Ghodadra’s discussion of 3D printing imaging technology in a UPMC video.

Administrative Offices

only contact anyone has with Mary Jo Tutchko. Surgeons, residents, fellows, UPMC staff, visiting es about her work on behalf of Dr. Carl Snyderman, Dr. Paul Gardner, and Dr. Eric Wang in the

y Jo Tutchko: next week, ok?”

d for tomorrow and rescheduled the meeting.”

e you about your research project.”

ou received that directs you where to pick up your scrubs.”

nfirm you got that request?,” “I’ll get this to you as soon as we meet today’s deadline to submit the login.”

Ms. Mary Jo Tutchko

e recommended?”

he has prepared with course materials and instructions for students of the skull base course presented by the Center leaders. cused, addressing all incoming and outgoing details for the busy surgical team. Her swift handling, managing, and juggling of und role” doing the important work of supporting the Center physicians to ensure they have a good day that enables them to

onable and urbane as James Bond’s Miss Moneypenny; trim, savvy, and competent as Ironman’s Pepper Potts, the woman is

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UPMC Skull Base Surgical Team in International News From terminal diagnosis to “winning the Lotto,” describes the story of 18-year-old Aaron McMahon as presented in the Irish Examiner. Examiner Correspondent Eoin English reported the story of Aaron’s surgery at the UPMC Center for Skull Base Surgery.

Aaron’s father, Paul, is quoted in the story as saying, ““Dr. Gardner is probably one of the calmest doctors I’ve ever met in my life. We’ve been through every sort of emotion, but we were very, very calm, and optimistic and reassured by the team. Being reassured by one of the top neurosurgeons on the east coast of America was very reassuring for Aaron and that gave us some relief.”

Aaron’s 6-hour surgery resulted in total removal of the tumor from a critical region, surrounded by nerves that move the eye and the carotid artery. A team of five surgeons was involved; along with Dr. Gardner was ear, nose and throat specialist Dr. Carl Snyderman and their surgical assistants.

Neuroendovascular specialist, Dr. Tudor Jovin evaluated the carotid artery before surgery to determine the risk to Aaron if the artery were injured. MRI after surgery showed a complete removal of the residual tumor. Dr. Clayton Wiley in the department of neuropathology performed a complex pathological examination of the removed tumor and comparison with Aaron’s prior surgery. The result of this examination was that the tumor is a chondrosarcoma, which has an even better prognosis for Aaron.

Dr. Gardner reports that the UPMC team will see Aaron again for follow up to ensure full healing. “Aaron is released from the hospital but we will always need to watch for recurrence; however with complete removal, his previous radiation, and this refined and updated diagnosis his prognosis is excellent.” The multidisciplinary expertise provided at UPMC for this patient has made a dramatic difference in his long-term outcome.

A massive fundraising campaign by the McMahon family and friends enabled Aaron’s travel to UPMC for surgery.

UPMC is acknowledged globally as one of the world’s top centers for specialized skull base surgery. Drs. Gardner, Snyderman, and Wang and the UPMC Skull Base Center’s involvement and experience with treatment of skull base tumors like chordoma and chondrosarcoma tumors is ongoing through their clinical research and through their close association with the Chordoma Foundation.

Winners! “Heal with Steel” “Heal with Steel”” was the winning team in the 2018 North American Skull Base Society “Jeopardy” contest.

The winning members of team “Heal with Steel” comprised Fellows from UPMC - Raj Mukherjee, MD, MPH of UPMC Department of Neurosurgery, Philippe Lavigne, MD of UPMC Department of Otolaryngology. and Georgios Zenonos, MD of UPMC Department of Neurosurgery.

The contest was among educational events held at the 2018 NASBS annual conference in San Diego and served to publicly acknowledge the UPMC physicians’ in-depth knowledge of skull base tumors.

Update on these winning physicians: Upon graduation in 2018, Dr. Mukherjee is now Assistant Professor and Director of Neurosurgical Oncology at Johns Hopkins. Dr. Zenonos has been awarded a Fellowship in vascular neurosurgery at the University of Miami; he returns to the UPMC surgical team upon completion of his Fellowship. Dr. Lavigne is now a 2nd-year Skull Base Fellow at UPMC. 4

The winning UPMC team above, left to right: Debraj Mukherjee MD, MPH, Philippe Lavigne MD, Georgios Zenonos, MD. The winning team was gifted educational texts from publisher Thieme.

You can read the Irish Examiner ‘s entire series on Aaron McMahon’s medical journey online.

Brain Tumor Research Reward Ezequiel Goldschmidt MD, PhD, received word from The Scientific Program Committee of Congress of Neurological Surgeons that his abstract earned him the Preuss Research Brain Tumor Award as a result of receiving one of the highest scores among nearly 1,500 submissions. He will present his work, entitled Cerebrospinal Fluid (CSF) Can Inhibit Wound Healing and Induce CSF Leaks by Inhibiting Angiogenesis, during the 2018 Congress of Neurological Surgeons Annual Meeting in October in Houston, Texas.

According to Dr. Goldschmidt, “The abstract that will be presented to other researchers and physicians at the meeting is only a small part of the work of the lab. We are trying to understand and make sense of healing of the endoscopic endonasal approach.”

“We recreate the healing process that takes place after surgery in the laboratory using cells from the nasal cavity and any tissues that were accessed and involved with the surgery. We are using a wound healing model and check the model against procedures the surgeons use in the OR and situations they encounter. We then investigate whether this model is useful for patients to improve the healing process and diminish problems associated with wound healing.”

The Wound Healing Laboratory for Neurosurgery was initiated in 2017 and resides in two physical locations on the UPMC medical campuses, enabling Dr. Goldschmidt and researchers to perform in vivo (living organism) investigations.

Farewell Dr. Fernandez-Miranda!

Skull Base Pittsburgh Summer Course 2018 The summer 2018 advanced skull base course taught by the Center for Skull Base Surgery leadership team of Dr. Paul Gardner, Dr. Carl Snyderman, Dr. Juan Fernandez-Miranda, and Dr. Eric Wang attracted surgeons from around the globe.

This summer’s 28 surgical attendees came to Pittsburgh from California, New Jersey, Virginia, and Wisconsin in the United States and internationally from Chile, India, Israel and the United Kingdom.

The “Complex Endoscopic Endonasal Surgery” course was established to offer advanced surgical decision making and advanced techniques for experienced skull base surgical teams.

This photo of the Center for Skull Base Surgery team marks a bittersweet moment in time for the surgeons.

Juan Fernandez-Miranda MD has accepted a position offered him by Stanford University in California as CoDirector of the Brain Tumor, Skull Base, and Pituitary Centers. Left to right: Carl Snyderman MD, Paul Gardner MD, Juan Fernandez-Miranda MD, Eric Wang MD. For his first-rate work, ultimate professionalism, and years of friendship, the Center thanks Dr. FernandezMiranda. “We wish him every success. We are so proud of him and can’t wait to see what he does at Stanford; and he always has a home at UPMC.” 5

Center for Skull Base Surgery University of Pittsburgh 203 Lothrop Street Suite 500 Pittsburgh, PA 15213 Directors: Paul A. Gardner, MD gardpa@upmc.edu Carl H.Snyderman, MD snydermanch@upmc.edu

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.

If you would like to learn more about our activities or sponsor a project, please contact the Eye & Ear Foundation.* To support the Center for Skull Base Surgery, please use the enclosed envelope or visit eyeandear.org. If sending a check, please make payable to the Eye & Ear Foundation.

The University of Pittsburgh Skull Base Team is pictured above.

Additional information about the educational and clinical work of the Surgeons of the Center for Skull Base Surgery is

www.eyeandear.org 203 Lothrop Street Suite 251 EEI Pittsburgh, Pennsylvania 15213 Tel: 412 864 1300 *The Eye & Ear Foundation is a non-profit (C)(3) organization created solely to support the educational and research efforts

of

the

Departments

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Otolaryngology

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Ophthalmology at the University of Pittsburgh.

found at: UPMC.com/skullbasesurgery 6