Brain Tumor and Neuro-Oncology Center - Cleveland Clinic

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16 Clinical Programs (continued) In 2007, further expertise in endoscopic surgery for skull base indications was provided with the addition of Dr. Burak Sade to the Skull Base Surgery Program. BTNC endoscopic neurosurgeons work closely with endoscopic sinus surgeons in Cleveland Clinic’s Head and Neck Institute to provide minimally invasive surgical management for skull base malignancies, in addition to pituitary region tumors. Pituitary and Neuro-Endocrine Center (PNEC) The Neuro-Endocrine Center has shown continuous growth since its inception in 2002, fostered by a close working relationship among members of the BTNC and the departments of Endocrinology, Diabetes and Metabolism; Neurological Surgery; Neuro- Ophthalmology; and Radiation Oncology. The close relationship has led to the development of highly integrated clinical care pathways, a common pituitary tumor research database and several joint research projects (see below). Clinical Care Pathways Clinical care pathways define the pre-hospital, perioperative and postoperative care for patients with secretory and non-secretory pituitary tumors. The development of new pathways has helped decrease patient length of stay, with equal patient outcomes. Academic Activities A prospective IRB-approved database has been established for all patients with pituitary tumors seen in the Neuro-Endocrine Center. Detailed preoperative endocrine testing, including Cortrosyn stimulation, is routinely performed for comparison to postoperative findings. New clinical care pathways have eliminated the routine use of perioperative steroids, thereby enabling the accurate determination of postoperative pituitary adrenal activity. Several retrospective analyses have been completed and are also in progress, including comparison of Gamma Knife vs. IMRT for BRAIN TUMOR AND NEURO-ONCOLOGY CENTER subtotally resected somatotrophic pituitary adenomas, case review of pituicytoma, an analysis of the impact of somatostatin on the efficacy of radiosurgery for somatotrophic adenoma, and an evaluation of the role of radiosurgery and postoperative pituitary insufficiency. Additional collaborative work with groups outside Cleveland Clinic has focused on what role mutations in the aryl hydrocarbon receptor interacting protein gene (AIP) may play in the formation of pituitary tumors, especially familial acromegaly (excess growth hormone secretion due to a pituitary tumor) or in the early onset of these tumors in the sporadic setting. This resulted in two publications in 2007-2008: Georgitisi et al, Proceedings of the National Academy of Sciences USA (PNAS), 104(10): 4101-5, 2007 and Clinical Endocrinology, 2008, in press. Teaching of residents and fellows has similarly been augmented through the establishment of the center. Endocrine residents routinely participate in outpatient evaluation with endocrinologists and surgeons. BTNC fellows are intimately involved in the outpatient, operative and inpatient care of all patients. Neurosurgery residents play a critical role in the inpatient and surgical care of these patients, and are frequently able to attend outpatient clinics. A joint conference involving endocrinology, neurosurgery, neuroophthalmology, neuroradiology and radiation oncology is held on the first Friday of each month, during which case presentations and management or visiting lecturers are presented. In addition, monthly pathology review sessions, where the pathological findings of each patient are reviewed jointly by the pathologists, endocrinologists and neurosurgeons (the Pituitary Interest Group), continue. These sessions are open to all interested parties and are held the first Monday of the month in the Pathology & Laboratory Medicine Institute. A dedicated Advanced Neurosurgical and Spine Skills and Simulation Laboratory (ANSSSL) has also been developed through the Pituitary and Neuro-Endocrine Center’s
2008 ANNUAL REPORT leadership, within the Department of Neurosurgery. A prime focus is the training of medical students and neurosurgery residents, as well as fellows and staff, in open, minimally invasive and endoscopic approaches to the brain and skull base, especially the anterior skull base via transnasal and para-sellar approaches. Neuropathology Neuropathologists Dr. Richard Prayson, Section Head, and Dr. Susan Staugaitis perform interoperative consultations and final pathologic diagnoses on more than 600 brain and pituitary tumor specimens each year. More than 450 of these specimens have been digitally captured for discussion at the BTNC patient management conferences. All glioma specimens are evaluated by a panel of ancillary immunohistochemical and molecular tests. The staff of the BTNC has indicated that the following panel is medically necessary because it provides additional information for prognosis and/or treatment planning: WHO Grade I Glioma • Ki-67 immunohistochemistry (proliferation index) WHO Grade II • Ki-67 immunohistochemistry (proliferation index) • P53 immunohistochemistry (surrogate marker for p53 point mutation) Molecular Diagnostic Test Volume (Reporting Period 1/1/2008-12/31/2008) Specimen Class Total 1p FISH Total 19q FISH • Fluorescence in situ hybridization (FISH) for evaluation of allelic loss of chromosomes 1p and 19q • (FISH for evaluation of Epidermal Growth Factor Receptor amplification is performed on WHO Grade II gliomas but billed to BTNC Research Account.) WHO Grade III-IV • Ki-67 immunohistochemistry (proliferation index) • P53 immunohistochemistry (surrogate marker for p53 point mutation) • Fluorescence in situ hybridization (FISH) for evaluation of allelic loss of chromosomes 1p and 19q • FISH for evaluation of Epidermal Growth Factor Receptor amplification • Analysis of 1p and 19q using LOH by PCR is performed on selected cases when this procedure provides more accurate or additional information. • Due to low volume of request, sequencing of TP53 is no longer performed in house, but can be performed on a “send-out” basis. • Testing of MGMT promoter methylation is also offered as a “send-out” test. Approximately one-third of the 1p/19q FISH analyses performed are Reference Laboratory procedures (patients are not BTNC patients at the time of request). FISH for EGFR** 1p LOH by PCR 19q LOH by PCR TP53 SEQ Totals Routine Surgical (SX)* 166 169 149 8 8 0 500 Surgical Outside Review (SO)* 7 8 1 0 0 0 16 Surgical Reference Lab Consult (SRC) 12 12 2 0 0 0 26 Procedure Only (PRS) 94 93 2 1 1 0 191 Totals 279 282 3 0 0 0 * Specimen Classes SX and SO are patients treated by BTNC physicians. ** Numbers do not include tests performed on WHO Grade II gliomas billed to research accounts. 17
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Page 5 and 6: 2008 ANNUAL REPORT Jeremy Rich, MD,
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