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Pediatric NeuroNews - A Team Approach for Pediatric Brain Stem Tumors

Pediatric NeuroNews Winter 2015

A Team Approach for Pediatric Brain Stem Tumors

Date: November 28, 2014


George Jallo and his colleagues have operated on numerous pilocytic astrocytomas, always working in conjunction with colleagues in other pediatric cancer specialties.
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George Jallo and his colleagues have operated on numerous pilocytic astrocytomas, always working in conjunction with colleagues in other pediatric cancer specialties.

Nearly four years ago, when Kaitlyn Dorman was 9 years old, her parents noticed that her left hand had a slight tremor, usually in the mornings. One night in February 2011, Kaitlyn dropped a glass of water because her hand could no longer hold its weight.  The next day, their pediatrician told Kaitlyn’s parents she might have a serious problem and urged them to bring her to a major academic medical center for a head CT scan.

At Johns Hopkins’ emergency room, they received a terrible shock: The scan revealed a large mass involving Kaitlyn’s thalamus, midbrain and pons. The MRI characteristics were consistent with a juvenile pilocytic astrocytoma, the most common benign pediatric brain tumor. Although surgery is often curative for this type of tumor, its location made total resection impossible without causing major morbidities, such as paralysis. Radiation therapy, while effective, would also cause significant damage to her developing brain and is used as a last resort.

“We say this type of tumor is benign,” says Johns Hopkins pediatric oncologist Eric Raabe. “But a benign tumor growing in such a sensitive spot is still devastating.”

Rather than go with a single approach, Raabe and other members of Kaitlyn’s care team decided on a combination of therapies. At their weekly multidisciplinary pediatric brain tumor meeting, attended by pediatric neurosurgeons, neuro-oncologists, radiation oncologists and other experts, the team decided to do a biopsy to confirm the tumor type, followed by chemotherapy to try to shrink it without causing deficits.

Johns Hopkins pediatric neurosurgeon Edward Ahn performed the operation that week, confirming the diagnosis, and soon after, Raabe followed up with a standard chemotherapy regimen for pilocytic astrocytoma. But the tumor didn’t respond. After a second standard regimen also failed, Raabe suggested a new mTOR inhibitor then being tested in a clinical trial at Johns Hopkins. MTOR inhibitors target enzymes involved in cell growth and replication. Kaitlyn and her parents readily agreed.

The trial couldn’t have come at a better time. As the tumor continued to grow, Kaitlyn gradually became paralyzed on her left side and wheelchair-bound. But soon after she started on the study medication, her tumor rapidly shrank. Though she had to stop after four cycles because it was affecting her liver function, a new MRI scan showed that the tumor was much smaller and no longer actively growing. On subsequent scans over the next nine months, the tumor continued to shrink, even with no further therapy. With the tumor no longer pressing into her brain stem, Kaitlyn quickly regained her function.

The multidisciplinary treatment that she received is a hallmark of Johns Hopkins’ model for treating pediatric brain tumors, says George Jallo, clinical director of pediatric neurosurgery. “The beauty of this approach,” he says, “is that no one physician is taking care of any single child. It’s a team of us doing checks and balances, and that leads to the very best outcomes.”

 

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