Small and Big Operations: New Tools of the Trade for Brain Tumors Nalin Gupta MD PhD Chief, Division of Pediatric Neurosurgery Departments of Neurosurgery and Pediatrics University of California San Francisco Disclosure The speaker has no financial interests in any commercial product or firm mentioned in this presentation Incidence of Childhood Cancer Cancer Types Age 0-14 0-19 All Cancer Sites Combined 15.1 16.6 Bones and Joints 0.7 0.9 Brain and Other Nervous System 3.2 3.0 Hodgkin Lymphoma 0.6 1.2 Kidney and Renal Pelvis 0.8 0.7 Leukemia 4.7 4.3 acute lymphocytic 3.7 3.2 acute myeloid 0.7 0.7 Non-Hodgkin Lymphoma 0.9 1.1 Soft Tissue 0.9 1.0 Other 3.2 4.4 (incidence per 100,000) SEER, 2006 1
Outline Major types of pediatric brain tumors Posterior fossa tumors Hemispheric tumors Sellar tumors Limitations of translational research brainstem tumors Introduction Brain and spinal cord tumors are the second most common malignancy in children Outcome is often dependent on several factors **Degree of resection Location. Benign tumors in critical locations are often unresectable Histological grade Three Major Locations Distribution varies between different cranial comparments supratentorial 54% infratentorial 41 spinal 5 2
Clinical Features Children have different patterns of clincal presentations; often a function of location I Posterior fossa tumors II Low grade hemispheric tumors III Sellar region Management Diagnosis symptoms, imaging! Surgery Radiation diagnosis, reduction of tumor burden! damage to dividing cells! Chemotherapy cytostatic, cytocidal! Investigational Agents biologic, immunogenic! 3
What are the Objectives? Degree of resection and tumor grade predicts overall survival; the goal should be GTR Acceptable neurologic morbidity should be estimated functional imaging and mapping reduce likelihood of post-op deficits Gross Total Resection Dotted line=<1.5cm 2 ; solid line=>1.5 cm 2 residual tumor Adapted from Albright, et al, Neurosurgery, February, 1996 safer! smaller! superior! 4
smaller! bigger! minimally invasive! faster recovery! shorter hospital stay! patient preference!?better results! greater experience! better control! outcome known! functional mapping! Where Are The Advances? A) Structure/Function Correlation of anatomical data with functional data Incorporation of imaging with operative data Creation of functional maps B) Targeted Drug Delivery and Radiation Treatment MR Spectroscopy Cho Cr NAA normal necrosis Cho Cre NAA Cho NAA tumor radiation necrosis LL 3.0 2.0 1.0 ppm 3.0 2.0 1.0 ppm 5
MR Spectroscopy MRI with MRS grid MRI with MRS Map MRS Map MRI: 9/17/01! Left 5th! MSI: 10/1/01 Left Index! Right Thumb! slow wave! 6
Subcortical Motor Tractography Case 1 - Supratentorial PNET 5 y/o boy, presented with seizures No focal deficit Left hemisphere mass, right-handed Resection will be dependent on location of speech cortex relative to mass Solution: Subdural Grid & Speech Mapping 7
Awake Craniotomy Propofol induction and IV narcotics, extensive local anesthesia Reduction of anesthesia during mapping procedure Language paradigm tested by cortical stimulation In children <10 years of age, implanted grids allow language mapping Brain Mapping - Subdural Grids Brain Mapping 8
Brain Mapping Case 2 - Supratentorial Glioma 3 y/o boy, presented with seizures No focal deficit Left hemisphere mass, right-handed Resection will be dependent on location of motor cortex relative to mass Solution: DTI * Cortiospinal Tract Mapping 9
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Case 3 - Craniopharyngioma 5 y/o girl, presented with several month history of left ear pain No local lesion Suprasellar mass, mild GH deficiency Goal: Presevation of endocrine function Solution: Endoscopic-assisted transsphenoidal procedure 11
Technical Advances Intraop MRI - real-time imaging Radiosurgery Targeted drug delivery Intraoperative MRI Guidance 12
Gamma Knife - C model 13
Summary GTR will remain primary treatment objective Ongoing trend towards reduction in XRT dose Development of biologic agents, especially for disseminated disease References Chang EF, Christie C, Sullivan JE, et al. Seizure control outcomes after resection of dysembryoplastic neuroepithelial tumor in 50 patients. J Neurosurg Pediatr 51:123-30, 2010 Souweidane MM. The evolving role of surgery in the management of pediatric brain tumors. J Child Neurol 24:1366-74, 2009 Qaddoumi I, Sultan I, Gajjar A.Outcome and prognostic features in pediatric gliomas: a review of 6212 cases from the Surveillance, Epidemiology, and End Results database. Cancer 115:5761-70, 2009 Sanai N, Mirzadeh Z, Berger MS. Functional outcome after language mapping for glioma resection. N Engl J Med 358:18-27, 2008 Kramm CM, Wagner S, Van Gool S, et al. Improved survival after gross total resection of malignant gliomas in pediatric patients from the HIT- GBM studies. Anticancer Res 26:3773-9, 2006 Gupta N, Berger MS. Brain mapping for hemispheric tumors in children. Pediatr Neurosurg 38:302-6, 2003 14
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