For pediatric brainstem tumors, operable is possible
Date: January 3, 2012
Eleven-year-old Hannah Daneker’s saga started in January 2010, when her mother, Lori, and father, Wayne, first noticed that their daughter’s speech sounded nasal and muffled. “We thought she had a cold,” Lori says, “but it didn’t go away.”
After her pediatrician suspected allergies, Hannah took a round of steroids, and her symptoms seemed to improve. But in the fall, they returned. Lori took Hannah to an otolaryngologist, who suggested insufficiency of palate. By December, seeking yet another way to track down the cause of Hannah’s worsening symptoms, her parents scheduled an appointment with a neurologist at a local hospital. The MRI he ordered revealed a large brain tumor in Hannah’s medulla.
The diagnosis kicked off what for Lori was a numbing several weeks of consultations and second opinions. Several physicians suggested chemotherapy as a first-line defense to shrink the tumor. Others said the tumor was inoperable or that surgery would only be able to remove a small portion.
Confused and uncertain, the family sought a consultation with Johns Hopkins pediatric neurosurgeon George Jallo. After reviewing Hannah’s history and test results, Jallo said surgery was her best option and that he’d probably be able to remove at least half of the tumor.
“This is an extremely uncommon location for tumors,” Jallo explains, “so most centers don’t have experience with it. As a result, they usually choose not to intervene until there are deficits, then recommend chemotherapy or radiation. But if you do good, aggressive surgery without hurting patients, you can avoid the need for any other kind of therapy.”
The primary risk associated with operating on this part of the brainstem is the slim margin for error. Because the medulla is vital for such functions as swallowing and breathing, straying just a millimeter from the boundaries of the resection could lead to permanent and devastating damage.
“These surgeries are really different from other tumor resections in which we add a significant margin when we take them out,” Jallo says.
In addition to the surgeons themselves, intraoperative neurophysiological monitoring specialists play a critical role. Eva Ritzl, who directs the team, explains that they keep tabs on a patient’s functions throughout surgery, tracking motor and somatosensory evoked potentials with inserted electrodes and using electromyograms to monitor cranial nerve function.
“Neurophysiology usually involves a routine test that gets interpreted later,” Ritzl says, “but we’re testing right here, right now, in the moment, to keep patients safe.”
Unlike smaller hospitals that don’t have an in-house team to provide intraoperative monitoring, Johns Hopkins’ dedicated specialists are specifically trained to handle the unusual operations that Hopkins neurosurgeons frequently perform.
“We have a strong relationship and team approach with the surgeons here,” Ritzl adds.
Hannah’s procedure was scheduled for March 4. After the operation, as her parents watched Jallo walking toward them, “we were trying to read his demeanor,” Lori says. “When he told us he got 80 percent, I was ecstatic. I couldn’t believe it.”
But an MRI the next day showed even greater success—95 percent of the tumor was gone.
Today, having concluded her physical and occupational therapy, Hannah is back to her pre-tumor life. Her speech is normal, she’s playing field hockey, and she’s riding her horse.
“There’s nothing,” Lori says, “that she can’t do.”
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