Focusing on patients part 5

Skull-base surgery team weaves tapestry of survival
(continued)

"It's really important before the surgery team tackles a case like this to know precisely what they are getting into," said Nemzek, who provided the road map for the surgeons, using sophisticated scans of the brain and skull displayed on light frames in the operating room.

A team of doctors and nurses led by otolaryngology surgeon Donald and brain surgeon Jim Boggan began the surgery with an incision through Cabral's eyebrow and down the side of her nose, and removed her eye and the cancerous ethmoid sinus on the right. Then they made a second incision from ear to ear up in her hairline, identified the part of the tumor that had invaded the intracranial space and removed all of it, ensuring that only the healthy tissue surrounding the tumor remained.

"Sometimes these surgeries take 24 hours," said Boggan, a professor of neurosurgery and co-chair of the skull-base team. "But our team approach ensures that we all know the patient and we've agreed on our strategy, bringing together our expertise in multiple areas to concentrate on a single patient. We believe it provides the best possible patient care."

Pathologist Regina Gandour-Edwards, another member of the skull-base team, was standing by in the pathology laboratory. Her task during the surgery was to analyze by microscope dozens of interoperative biopsies that the surgeons performed as they moved into the delicate task of removing the deadly tumor.

"You want to remove only what you have to but no more, and you're working in areas filled with major nerves that are vital to the patient's quality of life," said Gandour-Edwards, an assistant professor with advanced training in head and neck pathology. "So the surgeons are doing continual tissue sampling throughout the surgery, removing all the tumorous tissue they find and leaving only healthy tissue behind."

The number of interoperative biopsies can reach into the 70s, but this day it would number only 26 before Gandour-Edwards and the surgeons were satisfied they had excised all of Cabral's tumor. The team of a dozen doctors and nurses then painstakingly reconstructed the lining of Cabral's brain from a graft taken from her thigh, and they resculpted the tissue behind her face leaving only minimal scars visible.

The following day Gandour-Edwards and her pathology team reviewed every biopsy to ensure that their interoperative analyses held true under further examination.

"It's very challenging work, especially because it is at the interface between brain tissue and other tissues," said Gandour-Edwards. "There are more kinds of tissues in this area of the body than elsewhere, and there is the potential for scores of different kinds of tumors, compared to areas like the liver, where there are only a handful of possibilities. The diversity of the lesions is unparalleled, and you have to know all of the neural pathways as well as the specialized ones that occur in the face, head and neck area."

It was Gandour-Edwards who identified Cabral's tumor as a sinonasal undifferentiated carcinoma, a very uncommon but aggressive form of cancer that originates in the lining of the sinuses and has been recognized as a distinct form of cancer for only 12 years.

"It's one that often spreads widely before the patient recognizes that something is amiss," she said.

Cabral spent a few days in the intensive care unit after the surgery and about two weeks in the hospital, but she remembers little of this time except for the abiding presence of her husband, daughter and extended family.

"Patients' attitudes and their families' support have a really big impact on how well they do in the hospital," said Kathy Tuttle, the skull-base team's clinical coordinator who works closely with patients and their families from diagnosis through follow-up care.

The immediate mortality in cases like Cabral's is very low.

"The long-range outcome depends on the stage at which a patient is treated," said Donald. "But when we are able to remove all the tumor while it is still confined to the immediate area, as we did in JoAnn's case, the outcome is excellent."

To search and destroy any remaining stray cancer cells, Cabral received both radiation and chemotherapy following her surgery, a process she likens to street-sweeping. And she continues to have follow-up MRI exams that are evaluated at UC Davis, where the skull-base team monitors her progress.

"I am truly in awe of the care I receive at UC Davis: I know they saved my life," said Cabral, who is wearing a patch until the team feels she is ready for a prosthetic eye. "I'm learning to adjust to the lack of depth perception, and my peripheral vision is different. I also have a little numbness. I can't feel my nose running, and that drives me nuts. But I feel marvelous, and I'm looking forward to my new eye."

The skull-base team at UC Davis is an integral part of the cancer program, according to cancer center director Ralph deVere White.

"It is an area where we really have a lead in the field," he said. "Paul Donald, who heads the team, was the first president of the North American Skull-Base Society, when it was formed in 1989. And this program attracts patients from all over the world. One of the few teams in a highly specialized area, it is also one of the few that offers advanced training for new physicians. Our fellowship in skull-base surgery is one of only a handful available in the nation. And we are the only center in the state that does really big complicated cases."

Brain surgeon James Boggan works in concert with head and neck surgeon Donald to remove those parts of the tumor that have penetrated through the brain case.