Pediatric Neurooncology Program

Brain tumors are the second most common neoplasm in children, second only to leukemia. We have in place at BCCH a formal Neurooncology program. This is led by Dr. Juliette Hukin, a pediatric neurologist with specific additional training in Pediatric Neurooncology. The program is multidisciplinary, with representation from neurosurgery, neurology, pathology, radiology, nursing, psychology, radiation oncology, oncology, endocrinology, nursing, physiotherapy, occupational therapy, and social services. BCCH has been involved for over 20 years with the Children’s Cancer Group, and more recently with the Children’s Oncology Group (COG), which have coordinated multiple disciplines and multiple centers to work together to advance the treatment of childhood cancers. As a result, we have provided the most modern treatments for tumors of the nervous system (brain and spinal cord), and are continually updating our treatment protocols as more information becomes available. Through our involvement in COG, we have access to and frequently obtain guidance from the best consultants in any discipline for any tumor type.

At BCCH, from 1984 to December 2001, we have treated over 450 children with newly diagnosed brain tumors and more than 75 children with intraspinal tumors. Each of the two senior neurosurgeons have done over 300 operations to remove brain tumors in children (some before BCCH opened in 1982). We are very conscious of the importance of resecting as much of the tumor as possible, while maintaining the function of the child. We have been able to resect tumors more radically than many, and still maintain acceptable neurologic function. One of the outcome measure that indirectly reflects expertise at radical tumor resection is the incidence of CSF shunting in children with brain tumors. Children with posterior fossa tumors commonly have associated hydrocephalus, secondary to blockage of CSF pathways by the tumor. Persistent hydrocephalus may require a shunt procedure or a third ventriculostomy. The incidence of shunting or third ventriculostomy for hydrocephalus in association with posterior fossa tumors in children is less than 20% at BCCH. This is at the low end of any reported series. This reflects our ability to achieve radical resections of all types of posterior fossa tumors, thus opening up the CSF pathways that have may have been blocked by the tumor.

As mentioned above, the neurosurgeons at BCCH have developed a team approach to the management of these patients. All cases are routinely discussed among the three neurosurgeons and at a multidisciplinary conference. In many instances, the child receives the benefit of having two pediatric neurosurgeons working together for their surgical procedure. For some of the complex, but uncommon tumors, individual neurosurgeons have developed special expertise and the patients are directed to the neurosurgeon on the team with the appropriate expertise. For example, Dr. Steinbok offers expertise to patients with craniopharyngioma, and Dr. Cochrane for children with pineal region tumors. Dr. Singhal has been develop in with our ENT coleagues the transphenoidal surgery

Radical resections of tumor when appropriate are facilitated by the use of state of the art image guidance systems and intraoperative electrophysiologic monitoring, with the latter modalities being used particularly for spinal cord and brainstem tumors.

The development of neuroimaging techniques such as stereotactic guided techniques, 3D MRI, MR spectroscopy, and intraoperative ultrasound, allows accurate definition of the tumor and normal structures of the brain to help guide the neurosurgeons achieve a safe resection. New techniques such as functional MRI are being developed to assist us further in identifying whether essential structures are in close proximity to the tumor and if tumor can still be removed safely or whether these structures are enmeshed within the tumor thus rendering a complete resection impossible. CT PET is now availble to our patients to help us determine the extent of tumor affecting the brain in some more challenging cases.

We are fortunate to be have a dedicated neuropathologist to assist us in identifying the exact diagnosis and thus determining the most appropriate therapy.

Neuro-oncology is an integral part of the Division of Pediatric Hematology/Oncology/Bone marrow transplant. Some brain and spinal cord tumors are not cured by surgery alone. Through the pediatric radiotherapy program at the BC Cancer Agency, we are able to provide precise radiotherapy using photon beams in a conformal or stereotactic fashion. Some patients with small lesions may benefit from a stereotactic surgery approach available at the BC Cancer Agency. The present IMRT technology allows us to provide precise radiotherapy with minimal radiation to surrounding normal structures thus minimising long-term sequelae of therapy. We are presently developing the technology to provide stereotactic radiotherapy to children who require a general anaesthetic, in the mean time in situations where this is required we refer these patients to our colleagues with whom we collaborate.

In some situations chemotherapy is an essential component to therapy. Dr Hukin and the oncologists carefully determine the most appropriate medical therapy for any given brain tumor that is not cured by surgery alone. We direct the medical therapy, however some may be provided closer to home by our pediatric colleagues across the province. The more intensive chemotherapy including stem cell transplantation is provided at BC Children’s Hospital. We provide the most up to date therapies for children with brain tumors and are constantly collaborating with our colleagues across the world, but particularly in the Children’s Oncology Group to ensure that our patients receive the best treatment possible. Our oncology training program is the second largest in Canada and in the last ten years we have trained more Canadian graduates than any other program.

We believe in addressing the whole patient’s needs from a multidisciplinary approach with the assistance of our nursing staff lead by our neuro-oncology RN, neuropsychologist to assist in reintegrating children back into school, dietician to optimize nutrition, physiotherapists and occupational therapists to maximize rehabilitation, and spiritual care. Patient and family counseling services are provided by social workers and psychologists to provide practical assistance related to travel, finances, and accommodation. Counseling is also available to individuals, parents and siblings. As well, programs such as Art Therapy, Music Therapy, Play Therapy and Relaxation Programs are available. In addition, Dan Mornar leads the parent group and explores novel ways to support parents and families through this difficult journey. Respite care is available through Canuck Place. Our provincial palliative care program provides palliative care to patients and their families in the home, local hospital or hospice setting.

The field of research into the causes of childhood cancer began to shift dramatically during the 1990′s. This shift moved away from exploration of environmental causes, therapeutics and pharmacology and toward under-standing the underlying genetic and biologic bases of childhood cancer. The emergent consensus is that understanding the genetic changes inherent in childhood cancer will lead to new treatments that can be used in the fight against this disease. Future treatment will target tumor and related cells and avoid healthy ones undergoing normal development.