Barbara Hannan had loved spending summer days working from her home office in Connecticut, usually dressed in shorts and sandals. As temperatures cooled after Labor Day, it came time to switch back to real shoes. The communications consultant had a surprise waiting for her as she slipped into her go-to black flats: they didn’t fit. She could not get them on, not even a little bit. Pulling out her other shoes, Barbara discovered the same problem with seven pairs she’d worn the year before, as her size 8 feet seemed to have grown inexplicably over the summer. Little did she know that day that she was about to embark on a months-long journey that may have started with her feet — but that would take her all the way up to her brain before bringing her back to health. Thankfully she had Dr. Theodore Schwartz and his team at NewYork-Presbyterian Weill Cornell Medicine as her guides along the way.
At the time, in the fall of 2019, Barbara mentioned the sudden change in her foot size to her primary care physician, who told her not to be concerned. A month later, during an annual checkup with her endocrinologist, Barbara raised the subject again. Why did her shoes suddenly not fit? There was no obvious swelling. The doctor sensed her concern and wanted to know more. Blood tests revealed an alarmingly high level of growth hormone, and a follow-up MRI confirmed what the endocrinologist had feared: Barbara had a tumor on her pituitary gland. Not only was the tumor affecting her growth hormone levels, it was also getting dangerously close to her optic nerve and starting to wrap around her carotid artery. She needed to talk to a neurosurgeon about getting it out before it compromised her vision.
After a period of denial followed by some careful research, Barbara chose four surgeons at four different hospitals to evaluate her tumor and recommend a course of action. The first two had similarly dispiriting answers: Major open brain surgery to remove most — but not all — of the tumor, followed by a lifetime of medication and even radiation to keep the tumor in check and her pituitary gland functioning.
“I don’t think I’d ever even said the word pituitary before,” says Barbara. “I didn’t even know where it was located. I gave myself a crash course in what it is and what it does. They don’t call it the master gland for nothing. It regulates hormones, sleep, metabolism, you name it. These type of tumors are slow growing over several years, and can trigger your growth hormone to go into overdrive, creating all kinds of unwelcome effects throughout the whole body. In my case it was telling my feet to grow!”
Fortunately for Barbara, the third neurosurgeon she and her husband went to see had a different take on her tumor. It was so different, in fact, that they didn’t even meet Dr. Schwartz right away – the first doctor to enter the room was Dr. Georgiana Dobri, the neuro-endocrinologist on the faculty of Weill Cornell Medicine Neurological Surgery. Dr. Dobri works closely with Dr. Schwartz to provide collaborative care to patients like Barbara, whose conditions may call for a combination of medical and surgical solutions.
“When Dr. Schwartz and I first looked at Barbara’s chart, we saw immediately how close the tumor was to the carotid artery and optic nerves,” says Dr. Dobri. “That was probably why the first two neurosurgeons she spoke with said they couldn’t remove more than about three-quarters of it. Trying to remove it all would risk the optic nerve and cause a loss of vision. It was also approaching the carotid artery, making any attempt to get near it surgically that much riskier. Dr. Schwartz was confident he could remove it – but only if we could reduce its size a bit first to get it off the carotid.”
When Dr. Schwartz joined the conversation, he explained the strategy that he and Dr. Dobri were suggesting. Dr. Dobri would oversee a three-month course of injections of a drug called Somatuline Depot (lanreotide) to try to shrink the tumor. Once the tumor was a safer distance from the carotid artery and optic nerve, Dr. Schwartz would operate to remove it – and not by removing a portion of Barbara’s skull to reach it, but by using an advanced endoscopic endonasal approach that would allow him access to the tumor through her nostrils.
“Endonasal surgery is a fast-growing specialty within neurosurgery,” says Dr. Schwartz, who has pioneered this minimal-access approach. “I work with an otolaryngology surgeon on these procedures since we are navigating through the sinuses, which ENTs know best, and Dr. Abtin Tabaee is one of the best in the field. We use endoscopes to guide surgical tools through the nostrils and into the natural cavities in the head, and remove the tumor without having to disturb healthy parts of the brain. It’s not only less invasive, it’s also safer and more efficient, as it allows the surgeon to navigate to the tumor directly, not through the brain’s gray matter.”
Relieved to have an option that did not involve a lifetime of monitoring and medication, and being particularly impressed with the collaborative nature of the two doctors during the consultation, Barbara chose Dr. Schwartz to do her surgery. “My husband and I were quite frankly blown away by the laser-focused attention of these two physicians on the unique circumstances of my condition, and the obvious team approach they took,” Barbara shared. “That, combined with the exceptional credentials Dr. Schwartz holds in pituitary tumors, meant there was no need to explore the fourth planned consult. In my mind, Dr. Schwartz was the best — and that is what I wanted if I was to have surgery on my brain.”
Under Dr. Dobri’s care, Barbara began the course of injected medication that would try to shrink the tumor and allow the plan to work.
And then it was March 2020, and the world turned upside down. Barbara recalls a nurse administering her monthly shot out in her garage during the initial Covid-19 lockdown (as a way to be extra careful not to contract the virus as she awaited surgery), followed by hearing the news that non-urgent surgery had been put on hold.
“It was such a stressful time for everyone,” she says. “The uncertainty at the height of the pandemic in New York in April was a lot to handle for many reasons. I believed in the potential of the drug to reduce the tumor, at least to some extent, even thought it was not a certainty. I remained optimistic. I was committed to continuing with the shots to make sure that my tumor would be ready for Dr. Schwartz once he was able to operate.”
She was wise to do so, because her next MRI showed that the tumor had responded to the injections and had shrunk. A month later Dr. Schwartz called to say that restrictions had eased and he was able to do Barbara’s surgery. Of course she was nervous about traveling into New York City, which had so recently been the hottest of Covid-19 hot spots, and she was dismayed by new regulations prohibiting family members from accompanying patients into the hospital. Nevertheless, Barbara headed into New York for the procedure.
“Barbara’s tumor was tricky, but the pre-surgical medication had done its job,” says Dr. Schwartz. “The tumor had receded enough that we were able to get all of the tumor out except for a small part that was very stuck to the artery, which we destroyed with cauterization.” Barbara’s growth hormone levels came down to normal, and now she is off medication and in remission.
“We recommend that Barbara have blood tests and MRI scans periodically to make sure that little fragment doesn’t start making hormones again,” says Dr. Schwartz. “But I wouldn’t expect that she will have any future problems with this tumor.”
“Telling my doctors that my shoes didn’t fit may have sounded silly, but I know my own body better than anyone else does,” Barbara reflects. “I knew that something very odd was going on, even though I had no idea the problem was not in my feet but in my head. I have become passionate about the importance of being your own health advocate. If I had stayed quiet and just purchased all new shoes, I could have gone blind as the tumor reached the optic nerve. You have to speak up.
“You also have to do your research, and don’t accept the first or even second opinion, especially when the stakes are high,” she notes. “If I had gone with either of the two surgeons who said they couldn’t get the tumor out, I’d be on medication for life. Finding Dr. Schwartz, Dr. Dobri, and Dr. Tabaee was the best thing that could have happened to me – having them working together as a team made all the difference in the outcome, and in my future.”
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