Skull Base Surgery: Present and Future; Drs. Frank Hsu, Edward Kuan, Dennis Malkasian, Alexander Himstead. University of California, Irvine.

SUMMARY: Drs Frank Hsu, Head of Neurosurgery at UC Irvine; Edward Kuan Professor of Otolaryngology and Co-director of the Comprehensive Skull Base program; Dennis Malkasian, Neurosurgeon, Molecular Biologist, and Anatomist, and Alexander Himstead, PGY 4 in Neurosurgery, moderated by Dr. Ausman, have an intergenerational discussion on the Present and Future of Skull Base surgery. The panel’s ages range from 30 to 80’s with a wide surgical experience. The field has grown from the gross removal of these tumors in complex locations to using minimal retraction, different corridors to reach the lesion, using advancing technology, and better understanding of the biology of the lesions to quality of life considerations and multimodality treatment.

With about 17,000 new primary brain tumors a year of which ~25% are acoustic and pituitary lesions, and 110 academic programs in the USA with skull base programs, are there enough cases to train competent skull base surgeons for the future? How is over-treatment controlled? Are Multi-Disciplinary teams of specialists the future of Skull base surgery? What are the limits of surgery? Is Proton Beam therapy with focused radiation only on the lesion, the future? What about the biology of the neoplasm? Will molecular treatments limit the use of surgery? NF2 acoustics have a genetic abnormality as do chordomas. Will DNA, RNA, or protein manipulation be the future? Should this interdisciplinary approach to managing complex medical problems be suited for academia rather than competing with the practicing physicians over routine cases? Should geneticists be part of a multidisciplinary team to mange these lesions? Will expansion into orbital lesions add a new dimension to the field? Is total removal the goal or quality of life and limited morbidity? When does a surgeon stop and why? In acoustic neuromas, is subtotal removal followed by radiation, sparing a 7th nerve deficit, lead to better outcomes? How aggressive should we be with benign disease?

Do multidisciplinary teams have better outcomes? How are diverse people in these teams to be compensated? Are Skull Base fellowships filled, and what is the future for the young surgeon? How will advancing technology with 3D imaging, MR 7-Tesla angiography and detailed imaging change skull base surgery? Is the future more sub-specialization where we know more and more about less and less be satisfying? Will surgery be eliminated as a treatment by 2100? 85% of diseases in the world occur in 85% of the population that lives in developing countries. How can these advances be brought to billions of people who have no access to them? Is the high cost of treating these lesions justified? Because skull based lesions are fixed, image guided surgery can avoid brain shift and allow better imaging at surgery. Does technology make a better surgeon or is good surgical judgment an essential component of success? How do you teach Judgment? What is the importance of the anatomy laboratory in refining the surgeons knowledge to utilize all modalities at his/her disposal? Can AI solve all these questions? Is an excellent patient outcome the goal over surgical or other treatments?

What are your answers to these questions which are fundamental to all of Medicine? Who is thinking about all of these factors and planning for the future? An outstanding discussion with many pearls of wisdom. See the upcoming video on the UCI team’s approach to chordomas and large meningiomas. How are all the above considerations used in the treatment of the patient? (60 minutes) Excellent for Video and Podcast. (JIA)