Treating Pediatric Brain Tumors

Understanding symptoms, treatments, and complications

Pediatric 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 pediatric brain tumor treatment

Brain tumor symptoms vary, but some common ones include:

• Mood and personality changes
• Persistent headaches, nausea, and vomiting
• Drowsiness, confusion, or memory loss
• Seizures or slurred speech
• Weakness or paralysis of half of the body or face
• Hearing loss or 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
• Blood tests
• Lumbar puncture (to examine the cerebrospinal fluid (CSF) for evidence of cancer, infections, inflammation and increased pressure in the brain)

The Pediatric Neuro-Oncology Board

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 pediatric brain tumor 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 brain tumor removal, minimizing collateral damage

While many hospitals conduct pediatric 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.

Advanced surgical technologies:

• Neuroendoscopy: A minimally invasive technique using a small incision in the skull through which tiny cameras and surgical instruments are passed.
• ROSA™ Robotic Assistant: A surgical robot that increases precision and safety, making neurosurgery safer, faster and more precise (Packard Children’s is also the only hospital in Northern California that deploys ROSA™, the robotic surgical assistant, for pediatric use).
• Intraoperative stereotactic guidance (ISG): Operates like a "GPS for the brain," ensuring surgeons know precisely where they are cutting relative to critical brain areas and the tumor’s boundaries.

Mapping the best course to the brain tumor

Carefully mapping the best possible surgical route to difficult-to-access tumors is key. Packard Children’s surgeons use advanced imaging technologies such as:

• Functional MRI (fMRI)
• CT scans
• Ultrasound
• Diffusion tensor imaging (DTI): A powerful technology for viewing brain connectivity.

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.

Awake brain surgery

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.

Therapies and treatments for pediatric brain tumors

• 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: 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.
• Clinical trials: 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.

• Adolescent and Young Adult Cancer Program: 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.
• Long-term follow-up: Pediatric brain 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 pediatric brain tumor treatment.
• Supportive therapies: Patients often benefit from psychological, physical, or occupational therapy during and after treatment.

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.