“Wellness is a connection of paths: knowledge and action.” – Joshua Holtz

PNA Spotlight: Dr. John Boockvar

This month the PNA Spotlight focuses on Dr. John Boockvar, vice chair in the Department of Neurosurgery and director of the Brain Tumor and Pituitary/Neuroendocrine Center at Lenox Hill Hospital in New York. He also serves as a professor of neurosurgery and otolaryngology/head and neck surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York. In addition, he directs the Laboratory for Brain Tumor Biology and Therapy at the Feinstein Institutes for Medical Research.

Dr. Boockvar did his undergraduate work at the University of Pennsylvania and followed in his father, grandfather, and great-grandfather’s footsteps to earn his medical degree from SUNY Brooklyn-Downstate Medical Center. He completed a surgical internship and neurosurgical residency at the Hospital of the University of Pennsylvania. He then did postdoctoral research training in neuro-oncology at the University of Pennsylvania Cancer Center, supported by the National Institutes of Health. He later served as professor of neurological surgery at Weill Cornell Medical College/New York-Presbyterian Hospital where he was co-director of neurosurgical oncology, head of the Laboratory for Translational Stem Cell Research and director of the Brain Tumor Research Group.

Dr. Boockvar was kind enough to answer a series of questions from the PNA. His answers follow.

Tell us about your educational journey. What stood out to you about each of the places where you spent time studying?

I did my undergraduate training at the University of Pennsylvania, and I think that’s where I was really taught neuro-psychopharmacology.  There I met pharmacology professor Steve Fluharty, who really got me thinking about chemistry of the brain, pharma-therapeutics of the brain, and the blood-brain barrier.  That was really impactful for me, as an undergraduate studying biology.  Then I went to medical school at SUNY Downstate in Brooklyn.  This was during the HIV AIDS epidemic in the early 90s, and so our hospitals were overrun with HIV/AIDS patients. It was really an incredible time to be a student, and to be hands on, battling one of the most dangerous, challenging diseases ever known. It instilled in us a strong work ethic that served us well decades later during the pandemic. We were well trained for that. I went back to Penn as a neurosurgery resident, where I fine-tuned my surgical acumen.

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Advanced Imaging Is Reshaping Pituitary Tumor Diagnosis

For patients with pituitary tumors—especially those with hormone-related conditions like Cushing disease—getting an accurate diagnosis can be one of the most challenging parts of the care journey. These tumors are often extremely small, sometimes just a few millimeters in size, and can blend in with normal pituitary tissue on standard brain MRI scans. In many cases, imaging leaves uncertainty about whether a tumor is truly present or where it is located.

At Mayo Clinic, a growing suite of advanced imaging approaches is helping close that gap—giving clinicians clearer answers and patients a more confident path forward.

Why seeing the tumor matters

Pituitary tumors sit in a particularly delicate area at the base of the brain, surrounded by critical structures such as the optic nerves and carotid arteries. Because surgery is often the primary treatment for hormonally active tumors, knowing exactly where a lesion is before entering the operating room matters. When imaging is inconclusive, patients may face additional testing, invasive diagnostic procedures or less targeted surgery.

Mayo Clinic neurosurgeon Dr. Jamie Van Gompel says improved imaging has a direct impact on care. Better preoperative visualization helps surgeons plan more precisely, avoid unnecessary exploration and focus treatment where it is most likely to succeed.

Expanding what imaging can reveal

While MRI remains the foundation of pituitary imaging, Mayo Clinic teams are using specialized sequences and complementary technologies to enhance what standard scans can show. These techniques are not used for every patient; rather, imaging is tailored on a case-by-case basis.

A 39-year-old woman with Cushing’s disease underwent CISS imaging of her pituitary gland. Image (A) clearly shows a lesion on the right gland. On a standard MRI (Image B), however, the same tumor was much harder to see and not well defined. The tumor was later surgically removed and confirmed to be the cause of her condition.

One such approach is contrast-enhanced CISS/FIESTA imaging, an MRI sequence that improves the visual contrast between pituitary tumors and normal gland tissue. In a Mayo Clinic study of patients with Cushing disease, this technique identified discrete pituitary microadenomas in 94% of cases, compared with 65% using conventional contrast-enhanced T1-weighted MRI alone. The tumors were also more clearly defined, helping clinicians distinguish true lesions from surrounding tissue.

A 67-year-old woman with Cushing’s disease had a T2-weighted (A) and contrast enhanced 3D T1-weighted (B) scans that did not show a clear tumor. A STIR scan (C) was able to detect a small abnormal area in the pituitary gland. This was later confirmed to be a corticotroph adenoma.

Advanced contrast-enhanced T2-weighted STIR imaging takes a different approach. By suppressing signals from a healthy gland, an adenoma stands out more clearly by comparison. This method may help not only with identifying small lesions, but also with defining the extent of larger tumors, including whether they extend into nearby areas such as the cavernous sinus. In published Mayo Clinic research, this technique successfully highlighted tumors that were not visible on standard MRI sequences, including lesions later confirmed during surgery.

A 67-year-old woman with Cushing disease had a preoperative T1-weighted scan (left) that showed no definite lesion. Dynamic contrast-enhanced PCD-CT (right) shows two distinct lesions (arrows) in the right pituitary gland, found to be pathology-proved adenomas.

In select cases, clinicians may also turn to a photon-counting detector CT, an advanced form of CT imaging that provides detailed iodine maps of the pituitary region. This technology has proven particularly useful when MRI findings are inconclusive, helping localize tumors that might otherwise remain hidden and reducing the uncertainty that can come with exploratory procedures.

Mayo Clinic radiologist Dr. Ian Mark emphasizes that the real strength lies not in any single test, but in having multiple advanced options available. Imaging strategies can be adjusted based on each patient’s symptoms, lab results and prior imaging—rather than relying on a one-size-fits-all approach.

From research to patient care

Several of these imaging techniques are already supported by peer-reviewed research and are in practice at Mayo Clinic. At the same time, ongoing studies are exploring additional ways to improve tumor detection, particularly for patients whose imaging remains negative despite clear biochemical evidence of disease.

Two active clinical studies are evaluating emerging approaches: one examining FET PET/CT imaging to help localize MRI-negative pituitary tumors, and another studying contrast-enhanced intraoperative ultrasound to aid tumor identification during surgery. Both are designed to further reduce uncertainty and improve precision in care.

A clearer path forward

For patients, advanced imaging can mean fewer unanswered questions and more confidence in treatment decisions. For clinicians, it offers a clearer roadmap for care before, during and after surgery.

By combining clinical expertise and a broad range of imaging capabilities, Mayo Clinic teams are helping ensure that pituitary tumors once considered uncertain or unseen are increasingly identifiable, allowing care to move forward with greater clarity and purpose.

Learn more about pituitary tumor care at Mayo Clinic and explore available diagnostic and treatment options.

PNA Medical Corner: Preventing CSF leaks

This month the PNA Medical Corner focuses on a study co-authored by PNA member, Dr. William Couldwell at the University of Utah Health in Salt Lake City.  The team looked at techniques to prevent leaks of cerebrospinal fluid in transsphenoidal surgery. They found that patients with sleep apnea can benefit from early initiation of positive pressure ventilation after transsphenoidal surgery with autologous abdominal fat (with or without fascia) grafting.

J Neurosurg

. 2026 May 29:1-10.

doi: 10.3171/2026.1.JNS251476. Online ahead of print.

The risk of cerebrospinal fluid rhinorrhea from early resumption of positive pressure ventilation after transsphenoidal surgery with autologous fat graft repair

Leo J Kim, Robert C Rennert, William T Couldwell

• PMID: 42214100  DOI: 10.3171/2026.1.JNS251476

Abstract

Objective: Multiple closure techniques may prevent CSF leak after transsphenoidal surgery for sellar lesions. In patients with obstructive sleep apnea requiring positive pressure ventilation (PPV), the optimal closure technique remains unclear. The authors assessed the efficacy of autologous abdominal fat graft repair for preventing CSF leaks in patients reinitiating PPV early after transsphenoidal surgery.

Methods: A retrospective cohort study was performed to review the records of consecutive patients who underwent microscopic transsphenoidal surgery with autologous fat (with or without fascia) graft repair between January 2018 and December 2024. Rates of CSF leak and other postoperative complications were compared based on the need for postoperative PPV.

Results: Among the 609 included patients (84.1% pituitary adenomas, 12.0% Rathke’s cleft cysts, 3.1% craniopharyngiomas, 0.8% meningiomas), 73 required PPV at baseline that was reinitiated at discharge (mean postoperative day 3.5 ± 2.9). No significant baseline differences existed between these groups. Twenty patients had persistent CSF leaks requiring postoperative CSF diversion or reoperation (3 PPV patients [4.1%] and 17 non-PPV patients [3.2%]; p = 0.99). Of these, the leak developed after discharge in 1 PPV patient (1.4%) and 6 non-PPV patients (1.1%) (p = 0.837). No difference in relative risk existed for CSF leak in the PPV and non-PPV groups (RR 1.16, 95% CI 0.320-4.198; p = 0.8108). There were no differences in other postoperative complication rates between groups.

Conclusions: Early initiation of PPV after transsphenoidal surgery with autologous abdominal fat (with or without fascia) grafting did not increase the risk of CSF leak, suggesting that it reasonably prevents leaks in patients with sleep apnea after transsphenoidal surgery.

Keywords: autologous fat graft; cerebrospinal fluid rhinorrhea; obstructive sleep apnea; pituitary surgery; positive pressure ventilation; skull base; transsphenoidal surgery.

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Cushing’s can be challenging, but there is support so patients can feel like themselves again. The main goal of treating Cushing’s is to get cortisol levels back to normal. This Pituitary Awareness Month, Xeris Pharmaceuticals® is highlighting the importance of one-on-one support for patients living with Cushing’s Syndrome and support for HCPs treating Cushing’s Syndrome.

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