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Treating Brain Tumors

The Childhood brain tumors vary in the symptoms they present, the cells that give rise to them, their location and the kinds of medical and cognitive complications they may cause. Treatments vary, too, depending on the type of tumor and the age, genes and health of the patient. At Lucile Packard Children’s Hospital Stanford, the brain tumor team’s first job is to assess the tumor and understand the patient.

Diagnosis and mapping optimal treatment

Brain tumor symptoms vary, but some common ones include mood and personality changes, persistent headaches, persistent nausea and vomiting, drowsiness, seizures, slurred speech, weakness or paralysis of half of the body or face, confusion, memory loss, hearing loss, impaired vision or trouble controlling body movements. Any combination of these symptoms should prompt a visit to a pediatrician, where a basic neurological examination is usually the first step in evaluation. If initial tests affirm the possibility of a tumor, the physician will typically order brain imaging scans, a blood test and a lumbar puncture, which examines the cerebrospinal fluid (CSF) for evidence of cancer, infections, inflammation and increased pressure in the brain.

At Packard Children’s, results are reviewed by the Pediatric Neuro-Oncology Board, a weekly meeting of world-class pediatric neurosurgeons, neuro-radiologists, radiation oncologists, neuro-oncologists, neuropathologists, social workers, neuropsychologists, rehabilitation experts and nurse practitioners. The board scrutinizes each case from every angle, mapping the best possible course to effective treatment. They leave no stone unturned, focusing their collaborative, creative and scientific attentions on each case to consider every treatment, innovation or relevant clinical trial.

Maximizing tumor removal, minimizing collateral damage

While many hospitals conduct brain surgery on children, relatively few focus exclusively on specialized pediatric procedures the way Packard Children’s surgeons do. This matters because young brains are different than adult ones on structural and cellular levels, so surgery can be aided a lot by a deep understanding of the developmental stage of each patient’s brain. Grasping the subtle differences significantly improves outcomes.

Packard Children’s specializes in surgical techniques that reduce exposure of the brain or spinal column, lower risk, shorten recovery time and minimize the disruption of healthy tissue. Neuroendoscopy, for example, requires only a small incision in the skull through which tiny cameras and surgical instruments are passed. Packard Children’s is also the only hospital in Northern California that deploys ROSA™, the robotic surgical assistant, for pediatric use.  ROSA™ makes neurosurgery safer, faster and more precise.

Mapping the best course to the tumor

Carefully mapping the best possible surgical route to difficult-to-access tumors is key. Packard Children’s surgeons use advanced functional MRI (fMRI) and CT scans, ultrasound, and a powerful new technology called diffusion tensor imaging (DTI). Experienced interpretation of these images can also make a big difference. Many hospitals use an automated protocol for reading fMRI to locate language and memory areas, for example. At Packard Children’s, images are always analyzed by highly trained pediatric experts.

Packard Children’s surgeons are also guided by a technology called intraoperative stereotactic guidance (ISG), which works like a personalized GPS of the brain. It ensures that surgeons know precisely where they are cutting relative to critical brain areas and the tumor’s boundaries.

One way to explore the function of tissue surrounding a tumor is to keep sedated patients awake during surgery and ask them to respond to questions or do simple tasks like talking, counting or looking at pictures. Awake brain surgery, which maximizes tumor removal and minimizes other damage, has proven effective in adults for decades. Packard Children’s is now pioneering the technique with children as young as 8 years old.

The surgical team:

Gerald Grant, MD, is the division chief and a world leader in the treatment of pediatric brain tumors.

David S. Hong, MD, is a pediatric neurosurgeon.

View our neurosurgery care team >  

Advances in the use of radiation to kill cancer cells

Radiation therapy may be used to reach tumors that are altogether inaccessible to the scalpel or to destroy cancer cells that might remain after successful surgery.

CyberKnife radiosurgery uses a beam of radiation, guided by real-time x-ray images mapped onto high-resolution MRI imagery of the patient’s brain, to destroy tumors without even entering the skull. Originally developed at Stanford, CyberKnife was first used for the treatment of pediatric brain tumors at Packard Children’s, where it is now an essential tool. 

Chemotherapy reaches cells surgery can’t

Some patients also benefit from chemotherapy, the use of drugs that are molecularly targeted to kill cancer cells. Most of these drugs work by interfering with the cancer cells’ ability to grow or reproduce. Chemotherapy is sometimes used alone, but it is more commonly combined with radiation, surgery or both.

Researchers at Stanford and Packard Children’s are investigating ways to deliver new chemotherapy drugs directly to brain tumors. One such effort, let by Dr. Gerald Grant, examines ways to get different kinds of drugs past the blood-brain barrier, the gate-keeping mechanism that keeps dangerous molecules (and potentially helpful drugs) out of the brain. Dr. Grant’s work may open doors to whole new kinds of chemotherapeutic drugs.

Stanford is currently running about a dozen brain-tumor-related clinical trials, including studies of new immune therapies and chemotherapy drugs, innovative combinations of chemotherapy and radiation, and new medications that may help address the memory and attention problems that patients sometimes experience after treatment. Packard Children’s is a key member of both the Pediatric Brain Tumor Consortium and the Children’s Oncology Group, opening the door for patients to participate in all relevant trials at the best children’s hospitals around the world.

Treating the whole patient for the whole time

Packard Children’s is committed to treating the entire patient, not just their medical malady. The Adolescent and Young Adult Cancer Program for example, engages patients in their teens and early twenties. These patients can grow especially isolated from their peers, and AYA seeks to make their experience less lonely and more meaningful.

Tumors occasionally recur and need to be treated again, and other illnesses may arise as byproducts of radiation or chemotherapy. It is important to identify and address such problems as soon as possible, so periodic multidisciplinary follow-up exams at Packard Children’s are an essential part of every patient’s treatment. Many children also benefit from psychological, physical or occupational therapy during or after treatments. Some patients maintain close relationships with Packard Children’s therapists and doctors through adolescence and into early adulthood.

The Packard Children’s team takes to heart that the best medical outcomes are achieved by engaging the whole patient — and the whole family, too. We stand by our unsurpassed technical and medical excellence, but just as importantly, we stand with our patients and their families.