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Treatment Options

There are several ways we can successfully treat your skull base tumor. Each has its own set of pros and cons. You and your team of surgeons will discuss these options and select the most appropriate one for you.  Here are the basics on each option.

Microsurgery:

This is the most common method of surgical treatment used for many skull-base tumors such as meningiomas, acoustic neuromas and cancers invading the cranium Surgeons utilize a very high-magnification operative microscope to work millimeters at a time to tease out tumor from normal nerves and blood vessels. Our surgical team is well versed in multiple complex microsurgical approaches, including orbitozygomatic, middle fossa, translabyrinthine / presigmoid, retrosigmoid and suboccipital craniotomy.

Microsurgery Pros:
  • Direct access to the tumor
  • Usually allows for complete removal of the tumor
Microsurgery Cons:
  • Requires general anesthesia and hospital stay
  • Longer recovery than endoscopic surgery or stereotactic radiation therapy (SRT)
  • Only for acoustics, there may be a slightly higher risk of facial nerve paralysis or hearing loss compared to SRT 

Endoscopic Surgery:

Endoscopic surgery is a catch-all phrase to describe any surgical procedure where fiber optic cameras are used to visualize the surgical field. Some procedures may be performed as “pure” endoscopic procedures which often require a minimal or invisible incision and opening in the skull less than the size of a nickel. Other procedures are combined, or endoscopic assisted, which allows the surgeon to see around corners and other areas not well visualized under the microscope. Many tumors around the pituitary can be approached through the nose, which requires no external incision!

What kinds of skull base tumors can be treated with endoscopic surgery

The endoscopic approach is only for tumors of the anterior skull base such as the pituitary and some meningiomas. It is not commonly used for acoustic neuromas, glomus, and epidermoid tumors.  At the Center for Skull Base Surgery, our specialists suggest the endoscopic approach always be discussed when considering any surgery. We think the two best words to describe the endoscopic treatment option are “minimally” and “invasive”.

Endoscopic Surgery Pros:

  • Minimally invasive/No scars
  • Little down-time
Endoscopic Surgery Cons:
  • Requires general anesthesia which carries its own small risk
  • Full access (for excision) may be limited around certain bony areas

           

Stereotactic Radiation Therapy

Stereotactic Radiation Therapy (SRT) refers to the precise delivery of radiation to a tumor to kill abnormal cells while minimizing collateral damage to normal surrounding structures. Like all other aspects of care for skull base lesions this requires a team approach with the surgeons and radiation oncologists working together to target therapy. Radiation may be used alone, or often follows surgery to prevent regrowth of a tumor.

What types of tumors are treatable with Stereotactic Radiation Therapy?

Small, well-defined, and/or malignant tumors often respond very well to SRT – stereotactic radiation therapy. Or, when endoscopic surgery cannot offer full access to a tumor, SRT is an effective, non-invasive procedure that carries little risk. Currently, there are three types of devices used for SRT – the Gamma Knife, the Cyberknife, and the LINAC system. Dr. Ashkan Monfared, ENT, chooses to use the Cyberknife since it does not require the patient's skull to be secured with bolts to a metal head frame.

”I realized early in my career that the only way of providing unbiased advice to patients regarding treatment options is to be proficient in all methods.  For this reason I trained as a microsurgeon, learned the art of stereotactic radiation therapy, and remain extremely vigilant about up-to-date research on skull base tumors.”

Ashkan Monfared, MD

SRT triangulates smaller-dosed beams of radiation into one very powerful source of energy. That radiation, coming from different angles in more tolerable amounts, protects surrounding tissues while at the same time, delivering the full, combined power of the energy to the tumor.

Treatment, usually from one to three sessions, is painless. Patients can go right back to their daily schedules. The best news is due to the optimized intensity of stereotactic radiation, almost 95% of small to medium tumors can be controlled with very minimal risks.  This data is only for schwannomas like acoustic neuromas. Meningiomas do not have such high rates of response.

SRT Pros:
  • Quick - no hospitalization, immediate return to daily activities
  • Non-invasive
  • Lower doses of radiation from triangulated sources
  • Minimal risks such as facial numbness
  • Shrinks or prevents tumor from growing
SRT Cons:
  • May increase secondary risk for cancer from radiation
  • Does not remove tumor
  • Future surgical removal of tumor may be more difficult due to scar tissue formation
  • May be classified as a pre-existing condition if patient's insurance carrier changes

Watchful Waiting

Sometimes the best treatment is no treatment at all. For benign, incidental tumors without any symptoms, we will follow a patient – balancing the risks of surgery against the risks of tumor causing problems.

The Pros Associated with Watchful Waiting:
  • No treatment risk factors as we delay treatment while actively monitoring your tumor. (Tumors are often very slow-growing. Watching and waiting may be best option for patients whose symptoms do not significantly interfere with their daily lives.
  • No surgical risk
  • No anesthesia risk
The Cons Associated with Watchful Waiting:
  • Your tumor could grow, become more difficult to treat, and could cause a significant health issue such as sudden hearing loss.
  • May be classified as a pre-existing condition if patient's insurance carrier changes

Endoscopic Surgery AND SRT Therapy

When tumors are large (measuring over 1 inch), and pose a significant risk of becoming more symptomatic, a combination of endoscopic surgery and SRT may be the best option.