March 15, 2012

Skull Base Center helps coordinate expertise, care

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Patient Care Coordinator Lesley-Ann Smith, left, talks with patient Glenda Lane, who came to the Vanderbilt Skull Base Center for surgery to remove a tumor that had grown from the hearing and balance nerve near her brain stem. (photo by Joe Howell)

Skull Base Center helps coordinate expertise, care

In brain tumors, as in real estate, it’s all about location, location, location. And no location is more perilous than the skull base.

It’s the interface between the brain and the head and neck and the home of critical structures, including the blood vessels to the brain and nerve pathways for blinking, eye movement, swallowing, smell, taste and facial animation.

Here, benign tumors can be just as threatening as malignant ones, as they grow and press on vascular and neurological structures.

“The skull base is almost a no man’s land,” said Reid C. Thompson, M.D., chair of the Department of Neurological Surgery. “These are the longest surgeries we do. It’s a really challenging, almost hostile, environment for surgeons to enter, and it requires expertise from a number of different teams.”

The Vanderbilt Skull Base Center brings together specialists in Neurosurgery, Neurology, Head and Neck Surgery, Otology, Radiation Oncology, Medical Oncology, Radiology, Plastic Surgery, Ophthalmology and Pathology.

The glue that holds all of them together is Patient Care Coordinator Lesley-Ann Smith. With patients traveling to Vanderbilt from the eight-state area surrounding Tennessee and needing to see multiple providers, Smith is an essential element in the Skull Base Center and a model for other programs to emulate.

“Lesley-Ann has become a lifeline for these patients to understand and navigate a complex medical system and the different surgical teams involved. Our patients benefit from the patient-centered approach enormously,” Thompson said.

When a patient is referred to the Skull Base Center, the patient care coordinator becomes their primary point of contact and coordinates their care from start to finish.

“The majority of our patients come from at least two hours away and we don’t want them making multiple trips or having to stay a week in town to get all the care they need. I advocate for these patients because they’re coming from far away and deserve a low stress, coordinated experience,” Smith said.

When Smith joined the Skull Base Center in March 2010, the average wait time for surgery was three to four months. Within a year, the wait was down to four weeks and surgical volume had doubled due to better coordination of surgeon availability and collaboration with OR management. The center now averages two surgeries per week.

The constant collaboration with specialists on each case is a key component as the patient’s treatment plan is developed.

This requires much planning due to the risky locations of these tumors and the many options available for surgery, radiation, chemotherapy and, in some cases with benign tumors, close observation.

The key is finding a balance between a cure and the risks and side effects of treatment. A surgical approach through the ear, for example, may destroy hearing but be the most direct path to the tumor.

“Some centers have a goal to do surgery or radiate depending on their level of expertise, but our goal is to do the right thing. We don’t have any bias to one treatment approach over another,” said David Haynes, M.D., professor of Otolaryngology and Neurological Surgery.

Radiation therapy has become an increasingly appealing option as technology improves. Vanderbilt’s expertise with image-guided radiation therapy (IGRT) allows the patient to be aligned within less than 1 millimeter accuracy to preserve sensitive structures surrounding the tumor.

“We used to determine the coordinates for targeting the tumor on day one and trust that the tumor was in the focus point on a day-to-day basis throughout the course of treatment. Now we can use on-board imaging while the patient is in position and can make adjustments robotically in real time,” said Anthony Cmelak, M.D., professor of Radiation Oncology.

Glenda Lane came to Vanderbilt’s Skull Base Center for treatment on her acoustic neuroma. (photo by Joe Howell)

Glenda Lane came to Vanderbilt’s Skull Base Center for treatment on her acoustic neuroma. (photo by Joe Howell)

The Vanderbilt Skull Base Center was recently named a “Center of Excellence” by the Acoustic Neuroma Association, an advocacy group for one of the most common types of skull base tumors. Acoustic neuromas grow from the hearing and balance nerve near the brain stem. Much of an acoustic neuroma surgery is spent dissecting it from the facial nerve, and an injury there can leave a patient unable to make facial expressions.

But three days after the removal of her acoustic neuroma, Glenda Lane was bright-eyed and smiling widely at the success of her surgery.

The Hixson, Tenn., native was vacationing in Florida when she had a terrible case of vertigo. A walk-in clinic there advised her to see an ear, nose and throat physician back home, and that’s when the tumor was discovered.

She was monitored with scans for two years, and the tumor grew rapidly. Her hearing ability also dramatically dropped. It was time for surgery, and even though Vanderbilt was more than two hours away, it was the top choice.

“Even my doctor in Chattanooga said he wouldn’t do this in Chattanooga or Atlanta. He told me to come to Vanderbilt,” Lane said.

Smith visited with Lane after her surgery and presented an itinerary with follow-up appointments. She had already arranged for Lane’s sutures to be removed with her doctor at home and for follow-up appointments with Haynes and Thompson.

Lane’s husband, Mike, said patient care coordinator’s like Smith act as the quarterback of the process.

“She takes all the doctors with different locations and schedules and makes them all come together on the same day. It’s wonderful.”