Home / Patient Stories / Removing complex pituitary tumor, neurosurgeon cures man's acromegaly

'It's life-changing, this operation': Israeli acromegaly patient shares story 

April 1, 2022 - By Dian Le

Juan Fernandez-Miranda was able to fully remove a pituitary gland tumor that was thought to be inoperable from Oren Barkan after a previous unsuccessful surgery in Israel. 

Here, Barkan is in clinic with Dr. Fernandez-Miranda and clinical instructor Dr. Karam Asmaro for a post-operative visit before returning home.

Photo Courtesy of Juan Fernandez-Miranda

High blood pressure, headache, and body pain: in early 2019, Oren Barkan visited his doctor because he was feeling unwell. Barkan, then 41 years old and a lawyer living in Israel, went through a barrage of tests, which found an extremely high level of growth hormone in his body.

Barkan was diagnosed with acromegaly, a hormonal disorder that develops when the pituitary gland produces too much growth hormone. A subsequent brain imaging scan showed a macroadenoma tumor in his pituitary, an endocrine gland at the base of the brain. 

Macroadenomas are benign – or noncancerous – tumors. However, they may cause serious side effects through the overproduction of hormones. Over the course of several years, excess growth hormone in Barkan's body had coarsened his facial features, and he experienced low energy, joint stiffness, and skin rashes. 

Barkan underwent surgery in Israel in February of 2019. But after surgery, a brain imaging scan revealed there was residual tumor hiding in his cavernous sinus.

In addition, Barkan's growth hormone levels shot back up and his former symptoms returned. Barkan's Israeli surgeon told him that no surgeon could remove the entire tumor, and Barkan would need to rely on medications for the rest of his life. 

Existing with a tumor invading his head, with a disease inadequately managed through medications, was untenable to Barkan.

"Living with a tumor in your head like this, it's not a good quality of life," he said. 

Barkan was not satisfied with his fate. So he went searching online: Why don't surgeons go inside the cavernous sinus?  On YouTube, he came across Juan Fernandez-Miranda, MD, professor of neurosurgery and director of Stanford's Skull Base Surgery program and Pituitary Center. 

In a series of online videos,  Dr. Fernandez-Miranda demonstrated his ability to successfully remove complex pituitary tumors from the cavernous sinus using an advanced endoscopic endonasal approach, in which the tumor is accessed through the nose rather than through the skull. 

Years of contributions to the development and refinement of this technique have provided Dr. Fernandez-Miranda with deep expertise in endonasal surgery. 

Barkan sent Dr. Fernandez-Miranda an email requesting to meet. 

Dr. Fernandez-Miranda studied the cavernous sinus for over 15 years. He developed a surgical anatomy-based classification of the cavernous sinus. (Source)

'No-man's land'

A small cavity in the skull base that is only a few millimeters wide, the cavernous sinus contains critical nerves and the main blood vessel to the brain, the internal carotid artery. Surgeons once called it 'no man's land' because it was considered so difficult to access.

Barkan's tumor was widely invading the cavernous sinus, an area "where most surgeons do not dare enter because of the fear of injuring the internal carotid artery and the low chance for successful outcome," said Dr. Fernandez-Miranda. 

Dr. Fernandez-Miranda's experience with navigating the cavernous sinus spans over a decade. He operates the Neurosurgical Training and Innovation Center at Stanford (NeuroTraIn) where he has not only practiced dissecting human head specimens but also pioneered innovative techniques in skull base surgery. 

"Many years of research, training and surgical experience have allowed me to perform safe, gentle and accurate surgery within the cavernous sinus," said Dr. Fernandez-Miranda. 

"Not a lot of neurosurgeons in the world seem to be doing this surgery, it's a unique practice of Dr. Fernandez-Miranda," said Barkan. 

"I went to him because he was the only surgeon who told me, and I think showed everyone, that you can go inside this area," he said. "You can remove tumors from the cavernous sinus." 

Undergoing pituitary surgery

After several Zoom meetings, Barkan boarded the 15 hour flight from Israel to San Francisco.

In the days leading up to surgery, Barkan went through extensive testing and appointments, but felt at ease with his team of doctors. "I felt like I'm in really good hands," he said. 

Barkan's definitive surgery occurred at Stanford in December 2021. During the operation, Zara Patel, MD, associate professor of otolaryngology, and director of endoscopic skull base surgery at Stanford, inserted an endoscope –  a thin tube equipped with a light and  4K camera – along with surgical tools into Barkan's nose and sinuses to access the tumor. Then, working as a team, Dr. Fernandez-Miranda expanded the approach while Dr. Patel provided visualization to widely access the cavernous sinus and carefully remove the tumor away from the internal carotid artery and cranial nerves.

The surgery lasted nine hours, longer than expected, but in the end Dr. Fernandez-Miranda completely removed the tumor with no complications, said Barkan. 

"Mr. Barkan is now in complete remission and considered cured, based on his hormonal values and postoperative MRI study," said Dr. Fernandez-Miranda. 

Post-surgery, Barkan's quality of life has improved greatly. The previous symptoms caused by the surge in growth hormone in his body have almost entirely resolved, and Barkan is grateful to have found a surgeon who was able to remove his tumor after being told it was impossible. 

"It's life changing, this operation," he said. 

Request an appointment by calling 650-497-7777. More information about Stanford Pituitary Center can be found online

Stanford Pituitary Center

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