"Endoscopic Skull Base and Pituitary Surgery - An Update on the Program"

Transcript

• 00:00Good afternoon, everybody.
• 00:02I'm Ody Mendel from the
• 00:04department of neurosurgery, and I
• 00:05was asked to, and delighted
• 00:08to introduce the
• 00:09my colleague,
• 00:11doctor Boland Omay.
• 00:14Doctor May is, is an
• 00:16associate professor
• 00:17in the department of neurosurgery
• 00:19and otolaryngology.
• 00:21His,
• 00:22area of expertise is pituitary
• 00:24tumors, scar based tumors, and
• 00:25neurotrauma.
• 00:28He's one of the few
• 00:29surgeons actually in the United
• 00:30States who's able to do
• 00:32brain surgery through endoscopic means,
• 00:34and pituitary tumors fall very
• 00:36nicely into that category.
• 00:40Doctor Omay finished his, did
• 00:42his residency here at Yale,
• 00:44and I think he did
• 00:45residency in Turkey also. So
• 00:46he's he did two residences
• 00:48in neurosurgery,
• 00:49once in Turkey and one,
• 00:51and then had an opportunity
• 00:53to come here
• 00:54and was willing to go
• 00:55through another residency,
• 00:57in neurosurgery here at Yale.
• 00:59He then went and did
• 01:01the two fellowships,
• 01:03one in Cleveland Clinic,
• 01:06in neuro oncology, and then
• 01:07went to Cornell and did
• 01:09a minimally invasive
• 01:11skull based,
• 01:12fellowship,
• 01:13in Cornell and then was
• 01:15recruited back,
• 01:17after these fellowships to run
• 01:19the
• 01:20skull base and pituitary tumor
• 01:21and the neurotrauma
• 01:24service here at,
• 01:25at, Yale University.
• 01:28And so I think today
• 01:29he's gonna talk to you
• 01:30about his program that he
• 01:31developed, in a huge collaboration
• 01:33with the otolaryngology
• 01:34service about the
• 01:36skull based tumor program
• 01:38and the pituitary tumor. So
• 01:40doctor Omeh?
• 01:41So much. Okay.
• 01:44Thank you, Odi, for this
• 01:45nice introduction, and,
• 01:47thanks again for inviting me,
• 01:50and giving me this opportunity
• 01:51to, to share,
• 01:53what is happening,
• 01:55with pituitary tumors and the
• 01:56pituitary program.
• 01:59So, what I'll do, during
• 02:01this talk is essentially,
• 02:03going over the pituitary program
• 02:05and kind of tell you
• 02:07about it, introduce you to
• 02:08it as much as I
• 02:09can, and also go through
• 02:10what we have been doing,
• 02:13both as clinical activities,
• 02:15research,
• 02:16and education, like all these
• 02:17three, three pillars.
• 02:20So,
• 02:21the LQ-two thirty program is
• 02:22not new.
• 02:25Previously,
• 02:26doctor Spencer, our previous chairman,
• 02:29doctor Alain de Lobiniere,
• 02:32from neurosurgery,
• 02:33and ENT, doctor Sasaki, Bianchi,
• 02:36and doctor Mannes have been
• 02:37involved in it
• 02:38before I joined, and as
• 02:40well as doctor doctor Inzuki,
• 02:41who was,
• 02:43who was, in the pituitary
• 02:45the medical side of the
• 02:46pituitary world.
• 02:50So in its current condition,
• 02:52the Yale Pituitary Program
• 02:54stands as a tertiary referral
• 02:56center,
• 02:57for our states.
• 02:59And we get, we occasionally
• 03:01get consultations and referrals from
• 03:03other
• 03:04neighboring states as well.
• 03:07What we do is, we
• 03:08do complex pituitary surgery, complex
• 03:10cellular and paracellular pathologies,
• 03:14and,
• 03:14midline skull based pathologies,
• 03:17starting from the frontal sinus
• 03:19all the way into into
• 03:21dense, which I'll I'll talk
• 03:22about later.
• 03:25So what is
• 03:27what do we bring to
• 03:28the table essentially
• 03:30when we are talking about
• 03:31the ill pituitary program?
• 03:33We're doing minimally invasive surgeries,
• 03:36most commonly through the nose,
• 03:38but not necessarily just through
• 03:39the nose, can be through
• 03:40the eyebrow,
• 03:42and,
• 03:43and through the orbit as
• 03:44well.
• 03:45We use genomics, like all
• 03:47tumors that are removed,
• 03:49are whole exome sequenced.
• 03:51We have,
• 03:52continuous
• 03:53expert endocrinology
• 03:55coverage.
• 03:57We have an intraoperative MRI
• 03:58that treats the intraoperative MRI
• 04:00that we,
• 04:01as a standard use when
• 04:03we resect pituitary adenomas and
• 04:05other skull based tumors.
• 04:07We have,
• 04:08great expertise in radiosurgery.
• 04:13And then,
• 04:14we, of course, teach our
• 04:16residents,
• 04:16fellows, and, teach ourselves because
• 04:19this is such a collaborative
• 04:21approach.
• 04:22And,
• 04:24I think like I and
• 04:25and all of us, keep
• 04:27learning from each other. And
• 04:28that's that's and that's a
• 04:29wonderful thing.
• 04:31And we are doing as
• 04:32we, as we get more
• 04:33and more patients, more and
• 04:35more complex cases,
• 04:37we are able to carry
• 04:38this to cutting edge research
• 04:41as well.
• 04:43So I'll talk a little
• 04:44bit about the
• 04:46idea of center of excellence
• 04:47and the idea of pituitary
• 04:49center of excellence.
• 04:50So this has been,
• 04:52discussed in
• 04:54a in a couple of
• 04:55different publications,
• 04:57over the last decade.
• 04:59And, the idea behind it
• 05:01is that, you know,
• 05:02that this these kinds of
• 05:04surgeries,
• 05:05should be done in certain
• 05:07centers
• 05:08by, certain selected individuals,
• 05:11that creates
• 05:13and develop expertise in this
• 05:15by by experience
• 05:17and and and spending time
• 05:19on these,
• 05:20pathologies.
• 05:22And,
• 05:23they came up with this
• 05:24idea that a multidisciplinary
• 05:26team needs to be
• 05:27created,
• 05:29centered around neurosurgery,
• 05:30otolaryngology
• 05:32and endocrinology,
• 05:33but also involving
• 05:35other subspecialties,
• 05:37specialties as well, which I'll
• 05:38mention.
• 05:39And the idea that, you
• 05:40know,
• 05:42that an experienced pituitary surgeon
• 05:43has better outcomes and less
• 05:46likely to have,
• 05:48morbidity and mortality issues.
• 05:50And the ideal numbers thought
• 05:52to be the best for
• 05:53a pituitary surgeon was
• 05:56out of these studies thought
• 05:57to be about like fifty,
• 05:59adenomas,
• 06:00per year.
• 06:03So, the diseases that the
• 06:05pituitary center deals with is
• 06:07essentially
• 06:08a long a long list
• 06:09and this is partially because
• 06:10we are dealing with like
• 06:11midline pathologies and,
• 06:13and, there's excess of pathologies
• 06:15at the midline as we
• 06:16all know.
• 06:17So the big three are,
• 06:19pituitary adenomas, creopharyngiomas
• 06:21and meningeiomas. But everything we
• 06:23can think of can actually
• 06:25exist in these locations.
• 06:28So,
• 06:30to this list, you know,
• 06:31throughout, throughout our,
• 06:33life of our program, we
• 06:35added
• 06:35other pathologies such as meningoceals,
• 06:37dealing with sinus fractures through
• 06:39the nose,
• 06:41chondromas and chondrosarcomas,
• 06:43abscesses,
• 06:44mucor, and sometimes dealing with,
• 06:46CSF leaks from idiopathic intracranial
• 06:48hypertension.
• 06:49So essentially, we deal with
• 06:51pathologies of midline skull base
• 06:53from frontal sinus to the
• 06:54level of c two.
• 06:56That's the scope of, these
• 06:57approaches.
• 07:00And I just, you know,
• 07:01in in describing our team,
• 07:03I just brought the same
• 07:03slide that came from the
• 07:05Pituitary Center of Excellence
• 07:07papers. We actually, replicated,
• 07:10somewhat independently
• 07:12what exists as, what a
• 07:14Pituitary Center of Excellence should
• 07:16be.
• 07:17But I think on top
• 07:17of that, we have a
• 07:19significant support from our neurointensivists
• 07:21for the immediate postoperative care
• 07:23for these patients.
• 07:26We have significant supports,
• 07:28from
• 07:30data analysis and the way
• 07:32we exon sequence these
• 07:34tumors,
• 07:36and, and also neurovascular
• 07:38surgery. Having
• 07:40having an operating room that
• 07:42has immediate access to neurovascular
• 07:44surgery is also a great
• 07:45and unique thing that we
• 07:46have in our hospital.
• 07:50Our team. So,
• 07:53quite a group, and and
• 07:55I I find myself, like,
• 07:56extremely lucky that I am
• 07:58part of this group. And,
• 08:00I think we, the way
• 08:02we were able to work
• 08:03together,
• 08:04as we streamline these patients
• 08:06and and treat them, is
• 08:07is is a wonderful
• 08:09thing. And, it just gives
• 08:11me joy.
• 08:12I won't go through all
• 08:14the names, but I want
• 08:14to mention, Jan and Jenna.
• 08:17Jenna is here.
• 08:18So,
• 08:19these two people are essentially
• 08:21the backbone of the program
• 08:23like handling
• 08:24patients of not just day
• 08:26to day basis, but also
• 08:28in the long run. Like
• 08:30having a having
• 08:34a report with the patient,
• 08:36is extremely important,
• 08:38in these kinds of programs.
• 08:41So how do we
• 08:43approach the patient, the pathology?
• 08:45So these patients are referred
• 08:47from a, you know, a
• 08:48variety of different,
• 08:50locations. They can be incidentally
• 08:52found on random scans,
• 08:54endocrinology,
• 08:55ophthalmology,
• 08:56oriente. We can, you know,
• 08:57find them again somewhat, sometimes
• 08:59unrelated, sometimes related,
• 09:01fashion.
• 09:02The brain tumor center, you
• 09:04know, sometimes finds them and
• 09:05refers. And sometimes these patients
• 09:07are referred by,
• 09:09OB GYN services because, of,
• 09:11issues with fertility and hormone
• 09:13abnormalities.
• 09:14What happens is that these
• 09:15patients get referred to for
• 09:17a neurosurgical evaluation.
• 09:19And,
• 09:20once the workup is done,
• 09:21these patients are discussed in
• 09:22the pituitary conference.
• 09:25I forgot the ED. We
• 09:26also get a lot of
• 09:27consultations from the ED as
• 09:28well.
• 09:30Then after this evaluation,
• 09:32we have continued more advanced
• 09:33evaluation by endocrine, ENT, and
• 09:35ophthalmology if the patient is
• 09:36moving to surgery, and then
• 09:38they get their surgeries.
• 09:40Or if this is a
• 09:40nonsurgical condition, of course, they'll
• 09:42be treated medically.
• 09:44And after surgery, we have
• 09:45the genomics and pathology results
• 09:47and, you know, that either,
• 09:49you know, brings them for
• 09:50follow-up with endo endocrine and
• 09:52endo ophthalmology or if they
• 09:54need radiation therapy or neuro
• 09:56oncology needs, they'll be referred
• 09:58there. So this is kind
• 10:00of how things flow within
• 10:01the program.
• 10:03The workup,
• 10:04every patient who essentially gets
• 10:06evaluated gets a full neuro
• 10:08ophthalmological evaluation,
• 10:10a neuroendocrine
• 10:11evaluation,
• 10:12a pituitary protocol MRI,
• 10:15ENT evaluates them if they're
• 10:16going for surgery.
• 10:18We have a specific pituitary
• 10:20CT angiogram protocol that helps
• 10:22us navigate,
• 10:23during surgery as well as
• 10:25evaluate the,
• 10:27the the vascular risks.
• 10:29And then we have the
• 10:29capability of doing,
• 10:31inferior petroles or sinus sampling,
• 10:34especially for Cushing's disease.
• 10:37So the pituitary conference,
• 10:39happens over Zoom these days.
• 10:43We we deal with more
• 10:45complex cases.
• 10:47And usually the final decision
• 10:49about what to do with
• 10:50the patient is kind of
• 10:51decided there. There's a lot
• 10:53of teaching, the fellows, interested
• 10:54residents join that,
• 10:56and we learn from each
• 10:57other.
• 10:58It is a multidisciplinary
• 10:59environment
• 11:00and we sometimes get outside
• 11:02referrals as well to be
• 11:03discussed.
• 11:06In follow-up care,
• 11:09obviously we have neurosurgical follow-up
• 11:12after the surgeries.
• 11:14There's ENT, which is
• 11:16a parallel follow-up scheme. They
• 11:18have to see the patients.
• 11:20And then,
• 11:21and and they, because of
• 11:23the nature of these surgeries,
• 11:25the patients needs
• 11:28in office endoscopic evaluations
• 11:30and their noses are cleaned
• 11:31up, the crusting is removed,
• 11:33and that helps with healing.
• 11:35Endocrinology
• 11:36follows these patients,
• 11:37as well as ophthalmology and
• 11:39neuro oncology if necessary.
• 11:41And these patients, as new
• 11:43issues arise, are rediscussed in
• 11:45the pituitary conference and can
• 11:48be seen again and again.
• 11:49Our typical
• 11:50imaging follow-up
• 11:53strategy is doing a three
• 11:55month MRI, six month MRI,
• 11:57and then yearly afterwards.
• 12:01So over the years,
• 12:06during the early 2000s
• 12:08our case volume ranged between
• 12:10you know twenty five-twenty.
• 12:12And in the last, four
• 12:14or five years we're we're
• 12:15ranging around 60s,
• 12:17which is which is, I
• 12:19think the success of the
• 12:20program and
• 12:22all of us participating
• 12:23in it.
• 12:24But not only that, not
• 12:25only just the number, but
• 12:26also the the number of
• 12:28extended approaches, which means that
• 12:30not just cellular, pituitary approaches,
• 12:32but standard cellular approaches, but
• 12:34more like what we call
• 12:36tuberculum, I'll mention this later,
• 12:37or
• 12:39or clival approaches,
• 12:41or,
• 12:42or even, even more anterior
• 12:44frontal sinus or cribriform plate
• 12:46approaches are called extended approaches.
• 12:48So they're more complex. So
• 12:49those are also increasing in
• 12:51numbers.
• 12:52And not only that, the
• 12:54the way, the length of
• 12:55stay of these patients,
• 12:57are have also decreased over
• 12:59the years from about seven
• 13:01days on average to about
• 13:02four days on average.
• 13:05So those are all I
• 13:06think are our joint success.
• 13:11How do we deal with
• 13:12rare tumors? I mean, some
• 13:14of the tumors that we
• 13:15deal with such as craniopharyngeomas
• 13:17are so so rare that
• 13:18if we calculate, you know,
• 13:20the incidence with with the
• 13:21state's population,
• 13:23there's about seven point eight
• 13:24patients per year. Our average
• 13:26is about six craniopharyngiomas
• 13:28per year. So we are
• 13:28really getting, you know, almost
• 13:30all of them.
• 13:33Our endocrine team,
• 13:35is
• 13:37a robust group of specialists.
• 13:39We have sixteen faculty, four
• 13:40fellows.
• 13:42And
• 13:44what they do is that
• 13:45whenever a patient gets operated,
• 13:48not just on the pituitary,
• 13:49but in any area that
• 13:50can affect pituitary function,
• 13:52you get the endocrine consultation
• 13:54and they see patients throughout
• 13:55their hospital stay,
• 13:57and give us recommendations daily.
• 13:58This is extremely important for
• 14:00the,
• 14:01for the well-being and eventual
• 14:03fast healing of these patients.
• 14:05And then,
• 14:07of course, they move to
• 14:08outpatient follow-up.
• 14:10We have steroid protocols for
• 14:12specific,
• 14:13disease types,
• 14:14DI protocols,
• 14:16SIDH protocols,
• 14:17and early these types protocols
• 14:19that kind that follow sodium
• 14:20levels when the patients go
• 14:22home and make sure that
• 14:23they do not have issues
• 14:24with,
• 14:25especially SIDH.
• 14:28Our ENT service is another
• 14:30twenty four seven service that's
• 14:33that provides,
• 14:34for our patients.
• 14:36So ENT is not just
• 14:39an approach
• 14:40partner. They are a true
• 14:42partner in our surgeries. We
• 14:43do these surgeries together
• 14:45from beginning to end.
• 14:47So I I really cherish
• 14:49that partnership,
• 14:50and, again, I find myself
• 14:51very lucky that we have,
• 14:54the ENT team that we
• 14:55have. And our decisions are
• 14:57also jointly made,
• 14:59as we as we,
• 15:01diagnose, manage, and do the
• 15:03surgeries and do the follow
• 15:04ups.
• 15:07So I'll talk about the
• 15:09the pituitary gland now. I
• 15:10kind of move,
• 15:12move slowly
• 15:13to the the clinical aspects
• 15:15of things and what we
• 15:16do.
• 15:18So the pituitary gland is
• 15:19located in the center of
• 15:20the brain,
• 15:22look by location in a
• 15:23way, but also at the
• 15:24bottom of the brain. It
• 15:26is not in the brain,
• 15:27but immediately attached to the
• 15:28brain by a very thin
• 15:30structure,
• 15:31called the pituitary stalk.
• 15:35It's,
• 15:36it is located in a
• 15:38very complex
• 15:39anatomical
• 15:40region,
• 15:41bony wise complex with the,
• 15:44with the,
• 15:45main,
• 15:47sinuses all around it.
• 15:49And then neurovascularly
• 15:51complex with the carotid arteries,
• 15:53and superiorly
• 15:55anterior cerebral artery complexes.
• 15:59Neurally complex because we have
• 16:01the optic nerves kind of,
• 16:03and the chiasm just behind
• 16:05it,
• 16:06significantly neighboring,
• 16:08the pituitary gland.
• 16:10Not only that, to make
• 16:11the surgery more difficult, we
• 16:13have all these, like, intercarvernous
• 16:14sinuses that tend to bleed
• 16:16during surgery.
• 16:17So it is a it's
• 16:18a very tough place
• 16:20to, to reach. And that's
• 16:21why the,
• 16:23the endoscopic endonasal approach uses
• 16:25this natural corridor to be
• 16:27able to have access,
• 16:29to this, tough location.
• 16:32Physiologically, pituitary is also a
• 16:35unique organ.
• 16:37At the end of the
• 16:37day it's an endocrine organ.
• 16:39It's not a neural structure
• 16:40but it has, it has
• 16:41a connection to the brain.
• 16:42Its anterior lobe,
• 16:45secretes the the the the
• 16:47growth hormone,
• 16:48the prolactin, ACTH, l l
• 16:50h,
• 16:51FSH,
• 16:52and all the all the,
• 16:54essentially regulates all the hormonal
• 16:56activities in the rest of
• 16:57the body. And in the
• 16:58posterior pituitary lobe, we have
• 17:00the oxytocin,
• 17:04and vasopressin.
• 17:05These are,
• 17:06again, vital hormones,
• 17:09that come into play.
• 17:14The sella, the anatomical,
• 17:16the the bony structure that
• 17:17holds the pituitary gland, again,
• 17:19sits in the middle of,
• 17:21the sphenoid bone, which is
• 17:24a uniquely complex bone
• 17:26and and harbors,
• 17:27the necessary passages,
• 17:29that the neurovascular structures pass,
• 17:32through the brain towards the
• 17:33rest of the head. Most
• 17:35importantly, the carotid arteries and
• 17:37the optic nerves.
• 17:42So why is the endonasal
• 17:44approach so important?
• 17:46Because it gives us access
• 17:48through a natural corridor
• 17:50to a very unique location
• 17:52that is otherwise
• 17:54very hard to reach. Not
• 17:56just for the surgeon but
• 17:57also for the patient because,
• 17:59in before these approaches were
• 18:01developed, people
• 18:03approach these like through with
• 18:05great,
• 18:06I mean, very
• 18:07highly exposed operations that took
• 18:10significant amount of time and
• 18:11also required brain retraction.
• 18:15In this, in this picture,
• 18:16there's a there's a meaning
• 18:17geoma that's located in the
• 18:19tuberculum cella. And this is
• 18:20a post operative CT scan
• 18:22that shows the opening that
• 18:23was made to remove this
• 18:24meningioma at the base of
• 18:25the skull.
• 18:26So these are very small
• 18:28openings. I mean, this is
• 18:29a this is a rectangle
• 18:30like one,
• 18:32one by two centimeters in
• 18:33size.
• 18:35The endonasal approach by bringing
• 18:37the light source
• 18:38and the, and the camera,
• 18:41right where the pathology is
• 18:42creates these extremely crisp
• 18:45value illuminated images of anatomical,
• 18:47deeper anatomical structures that we
• 18:49would otherwise
• 18:50not have the capability of
• 18:52seeing.
• 18:54It can we we visualize
• 18:56the the skull base, like,
• 18:57covered with mucosa, but this
• 18:58is the sella and this
• 19:00is the clival recess.
• 19:01And it gives a very
• 19:02crisp,
• 19:04geographical
• 19:05understanding of, like, where things
• 19:06are. As we go deeper,
• 19:08this is the corgiopharyngeomary
• 19:09section. You can see the
• 19:10optic chiasm. And right here,
• 19:12this is the pituitary gland
• 19:13and the stalk, and the
• 19:14tumor is right there. So
• 19:15it gives us
• 19:18it gives us the capability
• 19:20of choosing the angle of
• 19:21approach and choosing the magnification,
• 19:25and essentially,
• 19:27bring the camera where the
• 19:28action is in a way.
• 19:29And this is a very
• 19:30unique picture where, you know,
• 19:32the tumor actually took us
• 19:33to the third ventricle, and
• 19:34we can see a ventricleostomy
• 19:36catheter going into the third
• 19:37ventricle. The forearm and Monroe
• 19:38are visible. And this image
• 19:40is taken from the nose,
• 19:42so the center of the
• 19:43brain. So it is a
• 19:44very unique approach.
• 19:47There are problems with it
• 19:48too.
• 19:49And,
• 19:50so this picture is essentially
• 19:51an open approach.
• 19:53Kind of to to the,
• 19:54optic chiasm.
• 19:56It gives it gives a
• 19:57more open visibility with brain
• 19:59retraction of course. But also
• 20:01the instruments can
• 20:03easily go in and out.
• 20:04As you can see, there's
• 20:05a bipolar and a suction
• 20:06device there. Doesn't work that
• 20:08well in endonasal approaches. And
• 20:10I always think of the
• 20:11example of,
• 20:14Heisenberg's uncertainty
• 20:16principle where what it says
• 20:18is like you cannot, you
• 20:19know,
• 20:20measure the momentum or the
• 20:22location of a structure or
• 20:24subatomic structure.
• 20:25At the same time, you
• 20:26have to let go of
• 20:27one of them to really
• 20:29understand something. And they all
• 20:31they equal to a constant.
• 20:33So,
• 20:34I feel the same as
• 20:35we operate. You know, if
• 20:36you want to see something
• 20:38in great detail like this,
• 20:39you know, this is the
• 20:41optic chiasm. These are superior
• 20:42hypophyseal arteries,
• 20:44extremely magnified picture, very crisp.
• 20:47But
• 20:48when we are seeing that
• 20:49we can't get instruments in
• 20:50because the endoscope is right
• 20:52there and taking up space.
• 20:54The space is so limited.
• 20:55If you bring the endoscope
• 20:56out and we can, we
• 20:58can bring the instruments in,
• 21:00but now we can see.
• 21:01So this surgery is always
• 21:03a balance of like
• 21:05of these like two, two,
• 21:07uncertainties in a way. And
• 21:09it's, the way we operate
• 21:11it's the, it's the function
• 21:13of the ENT surgeon during
• 21:14the neurosurgical portion of the
• 21:16case
• 21:17to almost direct
• 21:19the pictures,
• 21:20and bring the camera to
• 21:22where it's necessary to to
• 21:23do something and constantly, constantly
• 21:24play with this. And when
• 21:25I show videos, I you
• 21:26will be able to notice
• 21:27that
• 21:28as well.
• 21:35Adenomas, I mean this is
• 21:37a, we're talking about
• 21:38an organ that is like
• 21:39one centimeter in diameter
• 21:41but it creates all this
• 21:42complexity in terms of its
• 21:44tumors.
• 21:46The size,
• 21:47macrodynamo. Microadenoma differentiation,
• 21:49the function
• 21:51and if there's a function
• 21:52problem, what kind of function?
• 21:53These,
• 21:54these are the different subtypes
• 21:55of pituitary adenomas.
• 22:00So this is a pituitary
• 22:01adenoma. It is,
• 22:03a, it turned out to
• 22:04be, I mean we knew
• 22:04this before surgery but a
• 22:05growth hormone secreting
• 22:07tumor and the patient had
• 22:08acromegaly.
• 22:11I'll show you the, the
• 22:12operative video.
• 22:14There's a short version of
• 22:15it. So this is, we're
• 22:17already in the sphenoid sinus
• 22:19here and remove the bone.
• 22:21And, this is how we
• 22:23open the dura. Again, this
• 22:25is this is an opening
• 22:26about, like, one point five
• 22:27by one point five centimeters.
• 22:30So everything all the instruments
• 22:31that we use are extremely
• 22:32small, and this is just
• 22:33a very magnified picture. So
• 22:35this is the opening of
• 22:36the dura. The pituitary gland
• 22:37and obviously the pituitary tumor
• 22:39is a is an intradural
• 22:40but extraarachnoid
• 22:42structure. So we don't necessarily
• 22:43go into CSF space when
• 22:45we remove these tumors.
• 22:47And not going into CSF
• 22:48space is very important. That's
• 22:50something that we we are
• 22:51very careful about.
• 22:53So,
• 22:55these are of course,
• 22:58they're removing them is oncologically
• 22:59important. But from endocrine perspective,
• 23:02removing,
• 23:03the growth hormone secreting adenoma
• 23:06in totality is extremely important.
• 23:08So the surgeon,
• 23:10can be very aggressive,
• 23:12in terms of, like, trying
• 23:13to remove these tumors and
• 23:14risk CSF leak,
• 23:17if necessary.
• 23:18So here, what we see,
• 23:21in this picture is there's
• 23:22a suction device and there's
• 23:23a there's a
• 23:25an endoscopic forceps.
• 23:27And this is the tumor
• 23:28and this is the,
• 23:30the diaphragm. The diaphragm is
• 23:31the thin membrane of arachnoid
• 23:33that separates
• 23:34the CSF space from the
• 23:36from the cellar.
• 23:37So the the dissection is
• 23:39bimanual.
• 23:40So, the the endoscope is
• 23:42there and I'm there with
• 23:43like two two hands using
• 23:45one instrument in one hand
• 23:46and the suction on the
• 23:47left hand and trying to
• 23:48create a countertracture on the
• 23:50diaphragm so that we can
• 23:51actually dissect this tumor that
• 23:53is significantly attached to the
• 23:55diaphragm. That will have significant
• 23:56impact on the patient's outcome,
• 23:59in the years to come.
• 24:00Not just oncologically, but also
• 24:02from a systemic
• 24:03medical perspective because acromegaly is
• 24:05essentially a significantly
• 24:07morbid disease to have for
• 24:09a long if you have
• 24:10it for a long time.
• 24:13So this, bimanual dissection gives
• 24:15us the able ability to,
• 24:17you know, remove these tumors,
• 24:19much more effectively.
• 24:21So,
• 24:23after removing a large portion,
• 24:25it doesn't end there because
• 24:26usually there is tumor that's
• 24:27hidden, you know, at the
• 24:28backside of the
• 24:30the cella. So we have
• 24:31to lift up the diaphragm
• 24:32and kind of remove all
• 24:33these like extra tumor
• 24:35remnants,
• 24:36from that area. And as
• 24:38we do that, the diaphragm
• 24:39tends to fall down because
• 24:40it has it's filled with
• 24:41CSF and has a pressure.
• 24:42So it has to be
• 24:43gently pushed up, and the
• 24:45the seller needs to be
• 24:46explored for other remaining tumor.
• 24:55And then once we are
• 24:56satisfied, you know, it's time
• 24:58to explore and then, for
• 25:00other residual disease. And then
• 25:02we close. Sometimes we use
• 25:03fat graft to kind of
• 25:05replicate the,
• 25:07the the effect of the
• 25:09tumor on the diaphragm so
• 25:10it doesn't herniate.
• 25:11And then, and then we
• 25:12have a multilayer closure because
• 25:14at the end of today,
• 25:15we are doing a very
• 25:16small craniotomy. We are opening
• 25:18the dura. So we have
• 25:19to do a multilayer closure
• 25:21to
• 25:22to make sure that the
• 25:23the,
• 25:24the the sinuses and the
• 25:25nose is separated from the
• 25:27intracranial cavity.
• 25:34And this is the
• 25:35post surgery MRI, the tumor
• 25:37is remote and this patient
• 25:38did well.
• 25:40So, the indications,
• 25:42for these kinds of surgeries
• 25:44like any other neurosurgical
• 25:47problem, the mass effect is
• 25:48one of the reasons. Mass
• 25:50effect on the brain, mass
• 25:51effect on
• 25:52the optic chiasm.
• 25:54That is a very typical
• 25:55way these patients present with
• 25:57with pressure on the optic
• 25:58chiasm and region loss.
• 26:01Neurologic, ophthalmologic, or endocrinologic signs
• 26:04or symptoms. They can present
• 26:06with,
• 26:07a malfunction of the pituitary
• 26:09gland with hormone loss, or
• 26:10sometimes,
• 26:11a hyperfunction of the pituitary
• 26:13gland in acromegaly or Cushing's
• 26:15disease.
• 26:17So,
• 26:19and and then the need
• 26:20for tissue diagnosis somehow. We
• 26:22need to know what what
• 26:23the lesion is if if
• 26:24we are going to use,
• 26:27especially inject treatments.
• 26:30The other indications that I
• 26:32wrote in italic are kind
• 26:33of a little bit a
• 26:34little bit
• 26:35borderline. So, the need for
• 26:37en bloc resection of a
• 26:38tumor doesn't mean much in
• 26:40these tumors.
• 26:43And then a tumor lateral
• 26:45to the cavernous sinus, as
• 26:46long as it's not invading
• 26:47the cavernous sinus,
• 26:49we
• 26:50sometimes have the capability of
• 26:52like reaching out laterally
• 26:54to be able to bring
• 26:56these tumors into our space
• 26:58and remove them especially if
• 27:00they're soft in consistency.
• 27:03And then very large lesions
• 27:05like this case, you know,
• 27:07although they look frightening to
• 27:08begin with to be able
• 27:09to remove these from the
• 27:10nose, as long as these
• 27:11tumors are
• 27:15not extremely fibrous, they can
• 27:17be removed in piecemeal
• 27:19in totality.
• 27:23Our operating room
• 27:25is a little different because
• 27:27we use the instruments that
• 27:28we use are very different
• 27:30compared to standard neurosurgical instruments.
• 27:33We are operating
• 27:34through the nostrils,
• 27:36sometimes three hands, sometimes four
• 27:37handed approaches.
• 27:40This is the endoscope that
• 27:41goes in,
• 27:42and kind of constantly moving,
• 27:45and driven by the ENT
• 27:47surgeon.
• 27:48We have specific instruments that
• 27:49have, long shafts and,
• 27:52and,
• 27:54designed for endoscopic approaches. They
• 27:56are straight instruments
• 27:57as opposed to,
• 28:00other angles instruments that we
• 28:01use for microscopic surgery.
• 28:06We have an intraoperative MRI
• 28:07in our hospital. It's a
• 28:08three Tesla wonderful MRI,
• 28:10that we can actually
• 28:12before waking the patient up
• 28:13or even in the middle
• 28:14of surgery, we can bring
• 28:15the MRI in, not move
• 28:16the patient, bring the MRI
• 28:17in, get an MRI, get
• 28:19a great picture, and then
• 28:20decide on what to do.
• 28:23So, in most cases,
• 28:25once the patient wakes up,
• 28:26we already know, like, we
• 28:28know what we've done and,
• 28:29you know, it's it's kind
• 28:30of a done deal.
• 28:32Neuronavigation,
• 28:33is an important part of,
• 28:35what we do.
• 28:36So this is actually,
• 28:38showing in real time,
• 28:40where we are, in in
• 28:42a in a chosen type
• 28:43of imaging like a CT
• 28:44angiogram or an MRI. So
• 28:46when we are using our
• 28:47suction devices, suctions, the suction
• 28:49devices attached to navigation,
• 28:51wherever the suctions tip lands
• 28:54is actually shown on the
• 28:55neuronavigation,
• 28:57where it actually lands on
• 28:58the imaging.
• 28:59So it's an extremely useful
• 29:01tool, especially,
• 29:02if the surgical area is
• 29:04like a minefield and there
• 29:05are critical neurovascular structures that
• 29:07needs to be,
• 29:10managed.
• 29:13The
• 29:14the approaches,
• 29:16like I mentioned earlier, vary,
• 29:18whether they are towards the
• 29:20frontal sinus,
• 29:22or they're kind of like
• 29:24covering the anterior skull base,
• 29:26in the planum and tuberculum
• 29:27areas or they're towards the
• 29:29sella or towards the clivus.
• 29:31So, all this midline skull
• 29:33base can be covered,
• 29:36with these approaches going through
• 29:37the nose.
• 29:38All we have to do
• 29:39is essentially just change the
• 29:40angle of the scope
• 29:42and address the the structures
• 29:44there.
• 29:45So these are called transcribiform,
• 29:48if it's through the cribiform
• 29:49plates, transtuberculum,
• 29:50if it's tuberculum cella or
• 29:52transclival approaches if if it's
• 29:54true to clavus.
• 29:56A couple of examples. So
• 29:58this is a large macroadenoma.
• 30:01This is a typical cellular
• 30:02approach. Not much needed. Although,
• 30:04this small opening in the
• 30:05cell can remove this tumor.
• 30:07These are the post operative
• 30:08pictures.
• 30:11Sometimes,
• 30:13rare tumors like this epidermoid
• 30:15tumor as as seen in
• 30:16the restriction here,
• 30:18can be removed by, a
• 30:19cellular and a tuberculum
• 30:21approach,
• 30:22and using a corridor just
• 30:24above the pituitary gland to
• 30:25reach this,
• 30:26which would otherwise be a
• 30:28very, very tough target to
• 30:30reach.
• 30:33Meningiomas are also potential targets
• 30:35for these approaches. This is
• 30:36a
• 30:37cribriform
• 30:38anterior planum, meaning geoma located
• 30:41right in the anterior skull
• 30:42base.
• 30:43And, doing a craniotomy like
• 30:45this. This can be removed,
• 30:46with with relative ease without
• 30:48the need of brain retraction.
• 30:53Craniopharyngiomas,
• 30:54I have
• 30:56a specific interest in craniopharyngiomas.
• 30:58They are,
• 31:00they are rare tumors as
• 31:01I mentioned earlier and
• 31:03they they have significant consequences
• 31:06because they are although they
• 31:07are benign,
• 31:08they are very sticky
• 31:09and to recur a lot
• 31:10and,
• 31:12and
• 31:16if you handle the tumor
• 31:17in the wrong way during
• 31:18surgery, they can have catastrophic
• 31:20consequences.
• 31:22So,
• 31:23the way we approach these
• 31:24tumors again through the endonasal
• 31:25approach, we're going be, between
• 31:27the carotid arteries. And sometimes
• 31:29they can get really close
• 31:30and this is this is
• 31:32a sub centimeter corridor that
• 31:34we're going to utilize for
• 31:35this operation.
• 31:37So,
• 31:38again, the corridor is very
• 31:40important and,
• 31:41can feel discouraging if you
• 31:43look at a preoperative scan
• 31:45because for example, this case,
• 31:49the actual corridor that's going
• 31:50to be used is is
• 31:51between the pituitary gland and
• 31:53the optic chiasm and it's
• 31:55this and the target is
• 31:56behind it.
• 31:57But,
• 31:58it's a dynamic corridor. So,
• 32:01it still,
• 32:02does deliver in terms of
• 32:04the capability of removing these
• 32:05tumors.
• 32:07This was a study I
• 32:08did when I was a
• 32:08fellow.
• 32:10So this is one of
• 32:11our cases, one of our
• 32:12recent cases actually. Craniopharyngioma.
• 32:16So it's sitting right above
• 32:18the pituitary gland. You can
• 32:19kind of appreciate the differentiation
• 32:20of the pituitary gland and
• 32:21the actual suprasellar tumor.
• 32:24It's pushing on the chiasm
• 32:26and the patients presents with
• 32:28diabetes incipitus,
• 32:30which is common for to,
• 32:31craniopharyngiomas
• 32:32and also vision deficits.
• 32:37So, we are already done
• 32:38the bony work. So we
• 32:39are actually just cutting the,
• 32:41the the capsule of the
• 32:43craniopharyngioma.
• 32:45The
• 32:46this structure is the, pituitary
• 32:48gland, and we are actually
• 32:50operating above the pituitary gland
• 32:51in this case.
• 32:55So we have these, like,
• 32:55angled curettes that are also
• 32:57called pituitary curettes that are
• 32:58used to remove these kinds
• 32:59of tumors. We have specific
• 33:01bipolar coagulation devices,
• 33:04that we use to, coagulate
• 33:06tumor.
• 33:08And again, you see the
• 33:10the image constantly moving. That's
• 33:11because the,
• 33:13the ENT surgeon driving this
• 33:14endoscope is actually constantly bringing
• 33:17the camera down and removing
• 33:18it back on so that
• 33:19I can see and I
• 33:20can bring instruments in. And
• 33:22there's this constant,
• 33:24movement in these operations.
• 33:27So,
• 33:27ex exposure is extremely important.
• 33:29Removing like one little piece
• 33:31of a flap of Dura
• 33:32there, which is being done
• 33:33now, can
• 33:36increase the visualization
• 33:37significantly.
• 33:39But we can't we can't
• 33:40do this, you know,
• 33:42very widely because the carotid
• 33:43arteries are right lateral to
• 33:45that area.
• 33:46So as more tumors removed,
• 33:47you see the, the optic
• 33:49chiasm there which is which
• 33:50the tumor significantly attached to.
• 33:52And again, by bringing the
• 33:53camera closer and closer as
• 33:55much as possible, we can
• 33:56see the differentiation of the
• 33:57tumor and,
• 33:58kind of pushing it away
• 33:59from the chi as much
• 34:00as possible.
• 34:02The the force used for
• 34:04these maneuvers are exaggerated when
• 34:06you see them like this,
• 34:07but, actually, they're they're extremely
• 34:09mild maneuvers,
• 34:11for these,
• 34:13fragile structures.
• 34:22So, I'll fast forward a
• 34:23little bit. So, as the
• 34:24tumor is more more and
• 34:25more removed,
• 34:26we can see the chiasm
• 34:27in its full definition.
• 34:30The arteries that actually, that
• 34:32are seen, the small arteries
• 34:33that are seen in, occasionally
• 34:35that come into picture
• 34:36are called superior hypophyseal arteries
• 34:38that feed the chiasm, and
• 34:40they should be
• 34:41protected significantly. That kind of
• 34:43creates part of the challenge
• 34:44of these operations that,
• 34:47that those arteries cannot be
• 34:48divided.
• 34:50You can kind of appreciate
• 34:52them as the camera comes
• 34:53in and out.
• 35:00So this is a good
• 35:01picture of these, hypophyseal arteries
• 35:04and and the final kind
• 35:05of coagulation of the tumor
• 35:07right under the optic chiasm.
• 35:11Again, the opening here
• 35:12is about, like, you know,
• 35:14a little more than a
• 35:15centimeter,
• 35:16a square.
• 35:23This is another view of
• 35:24the chiasm and the super,
• 35:26super hypophyseal arteries.
• 35:28So,
• 35:29closure,
• 35:30so closure is very important
• 35:32especially in a case like,
• 35:34a craniopharyngioma
• 35:35because it's different than a
• 35:36pituitary adenoma. We are now
• 35:38in the intracranial space. We
• 35:40are intraarachnoid.
• 35:42There will be significant CSF
• 35:44leak and we have to
• 35:45really seal this defect.
• 35:46So we use,
• 35:48we use this technique called
• 35:50button technique. It's well defined
• 35:51in literature.
• 35:52Uses two different, dual substitutes
• 35:55tied to each other. And
• 35:56one goes inside, the other
• 35:58stays on, and they kind
• 35:59of keep themselves,
• 36:01in line.
• 36:02But most importantly,
• 36:06my ENT partners will create
• 36:07what we call a nasal
• 36:08septal flap,
• 36:10created a vascularized
• 36:11mucosal flap created from the,
• 36:14nasal septum,
• 36:16kind of created, twisted, and
• 36:18then kind of,
• 36:20replaced,
• 36:21right over the defect.
• 36:23These vascularized
• 36:24flaps create a full seal
• 36:26and can separate the sinuses
• 36:29from the,
• 36:31from the brain. And, it's
• 36:32a post operative picture. Looks
• 36:34like the, the tumor is
• 36:35remote and the chiasms are
• 36:37freely visible there.
• 36:39There's a lot of air,
• 36:39that's because we lost a
• 36:40lot of CSF during this
• 36:42operation and we made a
• 36:43hole at the bottom of
• 36:43the skull, but that's very
• 36:45well tolerated and goes away
• 36:46in a couple of days.
• 36:52So again, the post operative
• 36:54pictures and just,
• 36:55the image showing the the
• 36:56height of the openings is
• 36:58at,
• 36:58seven point eight millimeters.
• 37:02Sometimes,
• 37:03we use multimodal
• 37:05approaches.
• 37:06And these are,
• 37:07this is a giant,
• 37:09macroadenoma
• 37:10previously operated and recurred.
• 37:12So I approach it from,
• 37:14from from the nose endonasally
• 37:15but,
• 37:16parts of the tumor was
• 37:18really significantly stuck. Then I
• 37:19approach it, through a supraorbital
• 37:21approach,
• 37:23which is, which I'll mention
• 37:24later which is a, again
• 37:26a minimalistic way of doing
• 37:27a craniotomy and reaching these
• 37:29tumors
• 37:31using, again some natural
• 37:35access points.
• 37:38And then,
• 37:40one of the rare tumors
• 37:41like chondrosarcoma,
• 37:42that I did
• 37:44with
• 37:45my ENT colleagues,
• 37:47I think last year.
• 37:49So these are much rarer
• 37:50tumors. The patient is a
• 37:51young, male who presented with,
• 37:53right six nerve palsy. And,
• 37:54you can see there's like
• 37:56significant,
• 37:57posterior cavernous sinus lesion there.
• 37:59It's calcified.
• 38:01We don't know at that
• 38:01point what this was, but
• 38:02kind of sarcoma was in
• 38:04the differential diagnosis.
• 38:07So this is a different
• 38:08approach. This is a transclival
• 38:10approach,
• 38:12going below the the sella,
• 38:15between
• 38:16the periclival carotid arteries and
• 38:18right anterior to the brainstem
• 38:20right there. So these are
• 38:22the carotid artery impressions and
• 38:24then this is the clival
• 38:25recess that we're drilling to
• 38:26access this lesion. These are
• 38:28extra dural lesions so we
• 38:29don't have to open dura.
• 38:34There's a lot of drilling
• 38:35of the clival recess as
• 38:37we reach the tumor.
• 38:39So,
• 38:40and more and more opening.
• 38:42So, the the pituitary gland
• 38:43is is there kind of
• 38:44above this. It's covered with
• 38:46bone box. We don't need
• 38:47to open that necessarily.
• 38:54So this lesion was removed
• 38:56and blocked. It's a it's
• 38:58a,
• 38:59significantly calcified lesion.
• 39:01So, through this opening, you
• 39:03know, we are kind of,
• 39:04you know,
• 39:05dissecting it off from the
• 39:07neighboring dura.
• 39:09And then it will be,
• 39:11it will be removed and
• 39:12blocked.
• 39:15Chondrosarcomas
• 39:17as opposed to chondromas
• 39:18are located a little more
• 39:20off midline, but they are
• 39:21still accessible with these approaches.
• 39:24So you can see like
• 39:25how we go through the
• 39:26nose there. I, I, you
• 39:28know, I specifically kept this
• 39:29part so, people can understand
• 39:31like, you know, we actually,
• 39:32like, bring the scope
• 39:35through the nose and then
• 39:37you can see the corridor
• 39:38that we travel through the
• 39:39nose there. So these are
• 39:40called endonasal
• 39:41cases. There's our that because
• 39:44there is there's significant respect
• 39:46to the anatomical,
• 39:48structure of the nose.
• 39:49So we don't necessarily
• 39:51destroy much of the nose.
• 39:53There is there is some
• 39:54tissue removal, but it is
• 39:55not significant.
• 39:57So,
• 39:58the the chondrosarcoma
• 40:00is almost out now.
• 40:18And then it's just coming
• 40:19out from the nose.
• 40:25So I,
• 40:27show you one more thing
• 40:28here. This is so this
• 40:30is essentially
• 40:32if we had now that
• 40:33the tumor is out, if
• 40:34we had the capability of
• 40:35seeing through the dura that
• 40:37was that is right in
• 40:38front of us, this is
• 40:39actually the picture that we
• 40:40would be seeing, the basilar
• 40:42artery, and behind is the
• 40:43brainstem and the clival carotid
• 40:45arteries. So like posterior to
• 40:47the to this tumor there
• 40:48is significant,
• 40:50so this is a dura
• 40:51that I'm talking about. So
• 40:53behind it is the basilar
• 40:54artery and you can even
• 40:55see the pulsations of it.
• 40:57And,
• 41:06that so this was nicely
• 41:07remote, like, m block.
• 41:10The patient did well and
• 41:11the sixth nerve improved, the
• 41:12sixth nerve palsy.
• 41:17So I mentioned the supraorbital
• 41:19approach. So when we need,
• 41:20a really a transcranial approach,
• 41:22this is one of our
• 41:23options as a minimally invasive,
• 41:26surgery option. We can use
• 41:28the patient's eyebrow,
• 41:29as the incision point and
• 41:31they heal very well in
• 41:32the long run. And this
• 41:33is like an early post
• 41:34operative picture.
• 41:35And then the craniotomy is
• 41:36essentially this big. And then
• 41:38we we can do, we
• 41:39can open dura and go,
• 41:41under the frontal lobe and
• 41:43reach reach the target. And
• 41:45we can use an endoscope,
• 41:46through this corridor as well
• 41:47to to visualize and, do
• 41:49the resection.
• 41:50Again, very small opening about
• 41:52two centimeters.
• 41:54And then you can see
• 41:55the how the craniotomy looks,
• 41:57afterwards.
• 42:00So,
• 42:01how do genomics play a
• 42:03part in this after the
• 42:04surgery part is done?
• 42:06So all tumors that we
• 42:07remove,
• 42:08are whole exome sequenced,
• 42:11through, through our department.
• 42:13And the,
• 42:14the significant results, are discussed
• 42:16in our pituitary conference or
• 42:18relevant tumor boards if they're
• 42:19related to those tumor boards.
• 42:21We if we find mutations
• 42:23like BRAF mutations in craniopharyngiomas
• 42:25or or beta catenin in
• 42:27craniopharyngiomas
• 42:28or G NAS or USP
• 42:29eight in,
• 42:31pituitary adenomas,
• 42:32then
• 42:33there is relevance.
• 42:34Sometimes for diagnosis and sometimes
• 42:36for treatment. Hopefully more in
• 42:38the future. But currently, we
• 42:40have,
• 42:40BRAF inhibitors for BRAF mutated
• 42:42craniopharyngiomas,
• 42:43for example.
• 42:47We sometimes use IPSS,
• 42:49inferior petrosal sinus sampling,
• 42:52through an, endovas
• 42:54intravascular
• 42:55approach,
• 42:56with our,
• 42:57interventional neuroradiology
• 42:59colleagues.
• 43:00And that that can
• 43:01be of significant help when
• 43:03we cannot really decide
• 43:05where an ACTH producing adenoma
• 43:07is. When imaging is not
• 43:09enough, sometimes we just have
• 43:10to test each,
• 43:12draining vein from the,
• 43:14from the pituitary gland to
• 43:15kind of see where which
• 43:16side is coming from.
• 43:20Radiosurgery is a very important
• 43:22tool in dealing with these
• 43:23pathologies.
• 43:25And, we have extreme expertise,
• 43:28in our institution with Gamma
• 43:29Knife.
• 43:30And,
• 43:31this is a part of
• 43:32our our memorandum,
• 43:34to use Gamma Knife if
• 43:35necessary in dealing with these
• 43:37cases.
• 43:40So as we,
• 43:43you know, worked
• 43:44in our program and treated
• 43:46patients, we gathered a lot
• 43:47of expertise.
• 43:49And,
• 43:50and with
• 43:52Yale Medical School's expertise
• 43:54in
• 43:55in other research areas. This
• 43:56created a lot of clinical
• 43:57and molecular
• 43:58research and publications.
• 44:02I'll just go over a
• 44:02couple of
• 44:03highlights.
• 44:04So I have specific
• 44:07personal interest in pituitary apoplexy
• 44:09and I believe we see
• 44:10a little bit more than,
• 44:12we should statistically.
• 44:14I don't know why.
• 44:16But these are unique lesions
• 44:18and kind of, a very
• 44:19well recognized
• 44:21like,
• 44:22traditional disease,
• 44:24that is kept on asking
• 44:26neurosurgical examinations like what do
• 44:27you do with a pituitary
• 44:28apoplexy?
• 44:29So it's that kind of
• 44:30a disease. It's essentially,
• 44:32infraction or bleeding in a
• 44:33pituitary adenoma that causes sudden
• 44:35enlargement of the
• 44:37cellular structures causing immediate blindness
• 44:39and failure of the pituitary
• 44:41gland that can cause,
• 44:42hypoadrenalism
• 44:43and sometimes death if not
• 44:45recognized.
• 44:46So,
• 44:47we had a patient who
• 44:49had
• 44:50full of thymopllegia
• 44:51from that, and we were
• 44:53able to create an,
• 44:55an imaging,
• 44:56an imaging review that was
• 44:57published in an even journal.
• 45:00And,
• 45:01again, I just wanted to
• 45:02show mention this,
• 45:04talking about pituitary apoplexy,
• 45:06like almost in all cultures,
• 45:08there is this idea that
• 45:09there's a giant,
• 45:11which is, you know, essentially,
• 45:13probably because of a, a
• 45:14growth hormone secreting adenoma.
• 45:17And and these giants are
• 45:18usually have a vision problem.
• 45:19You know, they either have
• 45:20like a single eye, cyclopes,
• 45:22or they they have vision
• 45:23problems. They can't see well.
• 45:24And they usually die because,
• 45:26either a fall or somebody
• 45:28hits their head because they
• 45:29get a two three apoplexy.
• 45:31So that's
• 45:32the that's kind of like
• 45:34a a medical evaluation of,
• 45:36of the,
• 45:38of the myth of cyclopes.
• 45:43Other,
• 45:44other clinical research that we
• 45:45were able to do in
• 45:46our institution is we, we
• 45:48have the capability of doing
• 45:50not only intraoperative MRI, but
• 45:51also portable MRIs.
• 45:53And when we did these
• 45:54operations in non MRI rooms,
• 45:57we were able to bring
• 45:58a portable MRI and
• 46:00and do some imaging. And
• 46:01we were able to show
• 46:02that they are very actually
• 46:03helpful in,
• 46:05making sure that the decompression
• 46:06is done.
• 46:07What we wanted to achieve.
• 46:10So,
• 46:11that was that was actually
• 46:12very unique study.
• 46:15The molecular
• 46:17part of the, part of
• 46:18the research that we do,
• 46:20again involves
• 46:21deuteradenomas
• 46:22and all these rare tumors.
• 46:24I had a question.
• 46:26Again, I,
• 46:27I did this work in
• 46:28my fellowship.
• 46:30Try to correlate,
• 46:31that institutions,
• 46:34craniopharyngiomas,
• 46:36both molecular,
• 46:37to to pathology.
• 46:39And there was a group
• 46:40which was,
• 46:41adamant adamantimeters
• 46:43in in, in its
• 46:45pathological subtype, but there was
• 46:46there were no mutations found.
• 46:49And that was like an
• 46:50unknown at that point. And
• 46:51later on, you know, I
• 46:52operated on a craniopharyngioma,
• 46:54that turned out to have,
• 46:58a double loss of,
• 47:00APC gene.
• 47:03And that kind of almost
• 47:04answered this question that I
• 47:05had,
• 47:07about six years ago.
• 47:08And I think that was
• 47:09a very unique finding that
• 47:10we were able to publish.
• 47:15Not just oncology, but I'm
• 47:16also very interested in the
• 47:18hormone oxytocin. It's kind of,
• 47:20not,
• 47:21not enough attention is paid
• 47:22to oxytocin in my mind
• 47:23in the in the medical
• 47:24world and it's, it's it
• 47:26has very significant
• 47:28implications in,
• 47:31in in social behaviors, in
• 47:33happiness,
• 47:34and taking things easy, I
• 47:36guess.
• 47:37So,
• 47:38I have I work with
• 47:39the oxytocin expert from Child
• 47:41Study Center, Doctor. Rutherford, and
• 47:43we're working on, on our
• 47:45patients,
• 47:46that are,
• 47:48that are deficient in vasopressin.
• 47:52So I have a malfunction
• 47:53of the posterior pituitary gland.
• 47:55And we,
• 47:57we are at the,
• 47:59we are almost ready to
• 48:00publish our work that actually
• 48:01these patients have significant,
• 48:04social and psychological
• 48:05deficits taken there to oxytocin
• 48:07deficiency.
• 48:12Other research,
• 48:14I'm collaborating with Doctor. Arison's
• 48:16lab and
• 48:18we're looking into single cell
• 48:21transcriptomic analysis of two teradonomas.
• 48:24And it just it just
• 48:25shows us that these are
• 48:26extremely heterogeneous
• 48:28lesions,
• 48:29with different cell types.
• 48:32So we're, that's a work
• 48:33in progress.
• 48:36So the education,
• 48:37that's the third pillar of
• 48:39what we do.
• 48:40I mean, we train residents,
• 48:42we train,
• 48:43fellows. There are four fellows
• 48:45each year in the endocrine
• 48:46department
• 48:47And there's the ENT and
• 48:48neurosurgery residents.
• 48:50So,
• 48:51I work with I obviously
• 48:52work with neurosurgery residents, but
• 48:54I work with ENT residents
• 48:55too. And that's like, again,
• 48:56like something that I take
• 48:57pride in that, you know,
• 48:59I consider them, you know,
• 49:00my trainees as well. And
• 49:02that's, that's that's a unique
• 49:03luck. I think I, I
• 49:05think I have.
• 49:07And with with everything we
• 49:08have, including the the surgical,
• 49:11aspect of things, the the
• 49:12medical aspect of things, and
• 49:14the the pituitary conference,
• 49:17and the Gamma Knife, and
• 49:18the IPSS. Like, whatever is
• 49:19required
• 49:21for handling these diseases, we
• 49:23have it.
• 49:26What is the future? So,
• 49:28I see our program
• 49:30grow and evolve into a
• 49:32you know,
• 49:33a more national and even
• 49:34international
• 49:36entity. Hopefully we're
• 49:38we're trying to
• 49:39plan for creating sub programs
• 49:41for Cushing's disease and acromegaly.
• 49:44For research,
• 49:46I think this is all
• 49:47about collaboration and teamwork.
• 49:49Not just in the clinical
• 49:50side of things, but on
• 49:51the
• 49:52on the research side of
• 49:53things as well.
• 49:56So hopefully we'll we'll have
• 49:57an ultimate resolution of the
• 49:58molecular mechanisms of pituitary adenomas,
• 50:00which is still not known.
• 50:03We'll continue to work with
• 50:04oxytocin and we have the
• 50:05psychoneuroendocrinology
• 50:06lab, with doctor Rutherford that
• 50:08we're going to continue to
• 50:09work with oxytocin.
• 50:13I want to, thank to
• 50:15this long list of people.
• 50:16Without them, none of this
• 50:18would be possible.
• 50:20Thank you for listening.
• 50:32Questions?
• 50:46Oh, thank you.