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June 19, 2014
Two unrelated tumors for patient, same positive outcome
'I did not have a single side effect from either surgery'
Four months after Loyola surgeons resected a benign tumor from his nasal cavity, 18-year-old J.T. Mitchell returned to Loyola for a follow-up MRI.
As expected, there was no recurrence of the tumor, a juvenile nasopharyngeal angiofibroma (JNA). But the MRI did have a surprising finding: a new lesion, later determined to be a nerve sheath myxoma. This second tumor, located under the temporal lobe, had not appeared on earlier MRIs.
The two tumors were geographically and pathologically distinct, so it appears the lesions were unrelated. But the tumors did have one thing in common: Each lesion was successfully resected by a multidisciplinary team lead by otolaryngology and neurosurgery subspecialists at Loyola. “The key aspect of this case was having specialists working together under one umbrella,” said otolaryngologist Kevin Welch, MD. “Communication was seamless. There were no silos.”
First Tumor: Juvenile Nasopharyngeal Angiofibroma
At first, Mr. Mitchell thought his nasal congestion was hay fever. When his symptoms did not resolve, Mr. Mitchell saw a community otolaryngologist, who subsequently referred him to Dr. Welch, who specializes in sinus tumors.
A JNA is a benign tumor of the nasal cavity that exclusively affects adolescent males.
Symptoms include nasal obstruction, sinusitis and nosebleeds. Untreated, the tumor can grow and extend to the paranasal sinuses and even distort the eye and cause double vision. The etiology of JNAs is unknown, but it may be due to hormonal and genetic factors.
Mr. Mitchell’s tumor was 3.8 cm by 4.7 cm. Bleeding would be a major operative risk because the tumor’s thin-walled blood vessels could easily tear and rupture. To minimize this risk, Dr. Welch collaborated with neurosurgeon William W. Ashley Jr., MD, PhD.
Dr. Ashley is trained in both open and endovascular neurosurgical techniques. Prior to the resection, Dr. Ashley embolized the tumor’s blood vessels by injecting a liquid polymer into the blood vessels that fed the tumor. The polymer hardened almost instantaneously, cutting off blood supply to the tumor.
Traditionally, surgeons used an open technique to resect JNAs. This requires incisions in the face or mouth. In some cases, the upper part of the jaw has to be removed. Dr. Welch instead employed an endoscopic approach that went through a nostril. This approach does not require an incision, and it results in a faster and easier recovery, without scarring. But it requires considerable surgical skill and experience. Dr. Welch has used endoscopic techniques to resect dozens of JNAs and similar tumors.
Dr. Welch located and dissected around two major sensory nerves and several branches serving the upper mouth, cheek and nose. He cut the tumor into small pieces, using a device that vaporizes and coagulates tissue. To ensure the tumor does not grow back, Dr. Welch removed the core of the tumor in one piece.
Mr. Mitchell went home the next day, and six weeks after surgery, he rejoined his high school wrestling team.
Second Tumor: Nerve Sheath Myxoma
A nerve sheath myxoma is a rare, spindle-cell tumor that displays characteristics of both nerve cells and muscle cells. Mr. Mitchell’s tumor was located in the middle cranial fossa. In Loyola’s multidisciplinary program, neurosurgeon Vikram Prabhu, MD, and otolaryngologist Sam Marzo, MD, work in tandem on such tumors. This team concept also extends to other areas of cranial base surgery.
Drs. Prabhu and Welch collaborate on anterior cranial fossa tumors, while neurosurgeon Douglas E. Anderson, MD, and otolaryngologist John Leonetti, MD, collaborate on posterior cranial fossa tumors. Mr. Mitchell’s tumor was about 2.5 cm. in diameter. He had not yet experienced symptoms, which typically include headaches and seizures.
“It helped that we caught it when it was small,” Dr. Prabhu said.
Drs. Prabhu and Marzo have worked together for nearly 10 years. “We each bring a different expertise, to the benefit of the patient,” Dr. Marzo said. The surgeons carefully worked out a plan to do the resection in one procedure, while minimizing risks. Dr. Marzo said the tumor was a few millimeters from a facial nerve that controlled movements on one side of the face. The tumor also was close to the cochlea; drilling into the structure could cause deafness in one ear. A third risk was spinal fluid leakage.
Together, the two surgeons cauterized the tumor, then gently scooped it out. “It’s a delicate operation that has to be carefully planned and executed, with a watchful eye to avoid complications,” Dr. Prabhu said.
A nerve sheath myxoma is a sporadic tumor of unknown etiology. “We are reasonably confident we resected all of the tumor,” Dr. Prabhu said.
“We will keep monitoring Mr. Mitchell to make sure it does not come back.” Mr. Mitchell underwent both surgeries during his senior year of high school. Through it all, he was able to obtain good grades and graduate on time. He now is in community college studying for a degree in fire science, pursuing his dream of becoming a firefighter.
“I did not have a single side effect from either surgery,” he said.
“What a great kid,” Dr. Prabhu said. “He weathered this so well. Dr. Welch was kind enough to involve me in his case and I felt privileged to be a part of the team that took care of him.”